Failure to Provide Timely Incontinence Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide timely and adequate incontinence care and hygiene assistance to four residents, as evidenced by direct observations, interviews, and record reviews. One male resident with multiple diagnoses, including dementia, diabetes, and mobility impairments, was reported by a family member to have been left soiled for prolonged periods, with feces on his arms, hands, and under his fingernails. The family member stated that staff did not promptly provide hygiene assistance, and the incident was not documented in the facility's grievance records. Another male resident, cognitively intact and at risk for skin integrity impairment due to incontinence, was found in bed with soiled linens and a foul odor present in the room. The resident reported not being changed since the previous night, and staff confirmed that rounds had not been completed during the morning shift. Soiled linens and briefs were observed in the room, and staff indicated that rounds are sometimes delayed if other duties, such as showers, take priority. A female resident with a history of falls, malnutrition, and incontinence reported waiting approximately six hours to be changed after being soiled with feces, despite informing her assigned CNA. She was ultimately changed by the evening shift. Another female resident, also at risk for skin impairment, was found with a saturated brief containing urine and feces, and staff confirmed she had not been checked or changed prior to meals. Facility policy requires residents to be checked and changed at least every two hours and before and after meals, but this standard was not met for the residents reviewed.