Failure to Provide Timely and Complete Incontinence Care
Penalty
Summary
The facility failed to provide timely and thorough incontinence care for three residents who were dependent on staff for personal hygiene. Observations and interviews revealed that these residents were left wet or soiled for extended periods, with staff not responding promptly to call lights or checking on residents as required. In one case, a resident's spouse reported consistently finding the resident wet in the mornings and having to assist with care due to staff inattention. Direct observation showed the resident lying in a saturated brief with urine and stool, and staff did not cleanse all necessary areas during incontinence care. Another resident was found sitting in a puddle of urine with soaked bedding and clothing, stating they had been waiting all night for assistance. The call light was not within reach, and the resident was confused about its use. Staff acknowledged that night shift coverage was insufficient, making it difficult to provide timely care. A third resident, also fully dependent on staff, reported being left wet after using the call light, particularly during evening and night shifts. Observation confirmed the resident was left in a soaked brief for an extended period before staff responded. Facility policy required incontinence care to be provided as directed in the care plan, including checking residents every two hours, performing thorough cleansing, and applying barrier cream as needed. However, staff failed to follow these procedures, resulting in residents remaining wet or soiled for prolonged periods and incomplete cleansing during care. Interviews with staff and the Director of Nursing confirmed that these lapses occurred, and that inadequate staffing contributed to the delays in care.