Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with a history of congestive heart failure, diabetes, dementia, and adult failure to thrive was not provided timely incontinence care. The resident was fully dependent on staff for toileting and hygiene due to impaired cognition and mobility. Observations revealed a strong foul urine odor in the resident's room, and the resident was found lying in bed with yellow-brownish stains on her gown and underpad, indicating prolonged exposure to urine. The incontinence brief was moderately saturated, and the stains extended from the resident's hip to her shoulder, suggesting she had not been changed for an extended period. Interviews with staff confirmed that the assigned CNA had not provided incontinence care since starting her shift and was unaware of when the resident was last changed. The CNA also did not receive a report regarding the resident's previous care. The Director of Nursing verified that the CNA should have provided incontinence care earlier and acknowledged that the resident should not have had dried urine stains if care had been provided in a timely manner. Review of the facility's incontinence care policy showed it aimed to keep residents clean and dry but did not specify the required frequency of care.