Failure to Provide Timely Incontinence Care Resulting in Prolonged Resident Exposure to Wet Bedding
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including incontinence care, was not provided timely assistance, resulting in her remaining in a saturated brief and wet bedding for an extended period. The resident, who had diagnoses including atrial fibrillation, diabetes mellitus, decreased mobility, osteoarthritis, and non-Alzheimer's dementia, was cognitively intact and required two-person assistance for toileting. Her care plan specified that she should be kept clean, dry, and comfortable, with incontinence care provided as needed and regular monitoring for skin issues. On the day in question, the resident was last changed at 1:30 AM and did not receive further incontinence care until 10:30 AM, despite her usual care pattern of being changed two to three times during the night. During the 7:00 PM to 7:00 AM shift, the assigned nurse aide was unable to return to change the resident as planned due to a busy workload and lack of available assistance, and did not request help from the nurse. The aide reported off to the incoming shift that the resident needed to be changed, but the information was not clearly communicated or acted upon. The resident remained in a wet brief and bedding, as confirmed by observation at 10:30 AM, when two other nurse aides, not assigned to her care, found her saturated and provided the necessary care while preparing her for transfer to her wheelchair. Interviews with staff revealed that the resident's care was delayed due to staffing challenges and lack of communication between shifts. The unit manager was unaware of the lapse in care and stated that residents are expected to be checked and changed every 2 to 3 hours. The assigned day shift aide had not yet reached the resident before others intervened, and no one had reported the overnight lapse to her. The resident herself reported feeling wet and cold for several hours and had eaten breakfast in bed while still in a wet brief.