Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident with a history of cerebrovascular disease, psychotic disorder with delusions, vascular dementia, and major depressive disorder was not provided timely incontinence care. The resident, who was assessed as frequently incontinent of bowel and bladder and required assistance every two hours per their care plan, was observed sitting in visibly wet sweatpants in their wheelchair for over an hour. During this period, no staff were observed providing care or conducting room-to-room checks, and the resident's room developed a musty odor. Staff only attended to the resident after the issue was brought to the attention of the Director of Nursing by the surveyor. Interviews with the resident confirmed that second shift staff sometimes left them in a wet bed or brief for extended periods, sometimes up to an hour or more before being changed. The Director of Nursing verified the resident's condition and the musty smell in the room. Review of facility policy indicated that residents unable to perform activities of daily living independently should receive necessary services to maintain hygiene, but this was not followed in the observed instance.