Failure to Provide Timely Incontinence Care
Penalty
Summary
Resident #119, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, and diabetes, was identified as being frequently incontinent of bowel and bladder and requiring substantial to maximal assistance with toileting hygiene. The resident's care plan reflected these needs. On observation, the resident was found with a saturated incontinence brief and deep red discoloration on both buttocks, with a large dried yellow stain on the bedsheets beneath her. The resident reported that she had not been changed since the previous evening and that staff did not respond to her call light requests. Interviews with staff revealed inconsistencies in the timing and frequency of incontinence care provided to the resident. One CNA stated the resident was last changed at 6:00 A.M. on the day of observation, while the resident herself reported the last change occurred the previous evening. The facility's perineal care policy requires regular care to maintain cleanliness, comfort, and skin integrity, but this was not followed, resulting in prolonged exposure to urine and compromised skin condition for the resident.