Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident with a history of acute on chronic systolic congestive heart failure and major depressive disorder, who was cognitively intact but dependent on staff for activities of daily living (ADLs) including toileting, did not receive timely incontinence care. The resident experienced a decline in condition after a hospitalization, resulting in increased dependence for ADL care. On the evening in question, the resident was left in a soiled brief and bed linens saturated with urine for at least 10 hours, with incontinent care not provided until 6 hours after the issue was first observed. Observations and interviews confirmed that the resident's brief and sheets were soaked, and redness was noted on the buttocks. Staff interactions documented that the resident requested to use the bathroom but was told by a CNA to remain in bed for ease of care, and the resident was not assisted in a timely manner. Multiple staff interviews corroborated the lack of care, with one CNA finding the resident in a soiled state at the start of her shift. The facility's own policy required appropriate support and assistance with ADLs for residents unable to perform them independently, but this was not followed in this instance.