Failure to Document and Provide Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had diagnoses including hemiplegia, stroke, and Parkinson's disease, was cognitively intact but required maximal assistance with ADLs and was frequently incontinent of bowel and bladder. The resident's care plan required staff to check for incontinence every two hours and as needed. However, a review of the Point of Service documentation for the month showed multiple shifts across several days where incontinence care was not documented as provided. During interviews, the resident reported that staff did not check on him at least once per shift for incontinence care and that, when he used the call light to request assistance, staff sometimes failed to return, resulting in him being left in a soiled brief for hours. The DON confirmed that incontinence care should be performed and documented each shift and was unable to explain the missing documentation for the identified dates and shifts.