Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
A resident with dementia, muscle weakness, and a history of frequent bowel and bladder incontinence was not provided timely incontinence care and toileting assistance as required by his care plan. On the morning of the survey, the resident was observed lying in bed in a heavily soiled and swollen incontinent brief, emitting a strong odor of urine. The resident was unable to respond to questions due to severe cognitive impairment. Certified nursing assistant (CNA) staff confirmed that the resident had not been changed since the start of the shift, which began at 6:00 AM, and could not provide an explanation for the delay. During the provision of care, redness was observed on the resident's scrotum, and the charge nurse was notified to address the skin issue. Interviews with the charge nurse and the director of nursing (DON) confirmed that facility protocol requires staff to check and change residents at least every two hours. Both acknowledged that failure to provide timely incontinence care could result in skin breakdown and infection. Review of facility policy emphasized the importance of prompt toileting assistance to maintain resident dignity and quality of life. The deficiency was identified through observation, interview, and record review, which demonstrated that the resident did not receive care and services to meet toileting needs in accordance with the comprehensive assessment and care plan.