Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and hemiparesis, who was documented as always incontinent and dependent on staff for toileting, was not provided incontinence care at least every two hours as required by their care plan. On observation, the resident was found with a saturated adult brief, a wet bed pad, and a dried urine stain on the fitted sheet, indicating that incontinence care had not been provided for over four hours. The resident reported last being changed in the early morning, and the assigned CNA confirmed the last care was provided at 9:00am, despite facility policy and staff statements that care should be provided every two hours and as needed. Documentation and staff interviews confirmed the resident's need for frequent incontinence care due to heavy urinary incontinence.