Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL), specifically incontinence care, for two residents who were unable to perform these tasks independently. Both residents had severe cognitive impairment, as indicated by a BIMS score of 00, and were dependent on staff for toileting and personal hygiene. Care plans for both residents required staff to provide incontinence care every two hours and as needed, as well as to avoid doubling briefs to prevent skin breakdown. For one resident, observations revealed that he was found wearing two briefs, both heavily soaked with urine, and had not been changed for several hours. The assigned CNA admitted to not knowing when the resident was last changed and acknowledged awareness of the policy against double briefing. Another CNA from the previous shift also could not recall the last time the resident was changed and confirmed knowledge of the facility's protocols. Staff interviews indicated that training on proper incontinence care and rounding every two hours had been provided, but these practices were not consistently followed. The second resident, who was always incontinent and had a history of diabetes, acute respiratory failure, and stage 4 pressure ulcers, was observed in a room with a strong urine odor and a wet mattress cover. Staff provided incontinence care only after a significant lapse in time, with the assigned CNA stating the last change occurred before breakfast, several hours prior. Both the ADON and DON confirmed that staff were expected to perform rounds every two hours and as needed, and that nurses were responsible for monitoring CNAs. Despite these expectations and documented training, the required care was not delivered as outlined in the residents' care plans.