Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, multiple medical diagnoses including disorganized schizophrenia, heart failure, Alzheimer's disease, and cerebrovascular accident, was observed to have a saturated incontinence brief that had leaked onto the incontinence pad beneath her. The resident was dependent on staff for toileting and transfers, and was frequently incontinent of bladder and always incontinent of bowel. During an early morning observation, a CNA confirmed that the resident's brief was saturated and emitted a pungent odor, with leakage onto the pad. The CNA reported that the resident had last been changed approximately four hours prior, despite the expectation that incontinence care should be provided every two hours. This lapse in timely incontinence care was verified through medical record review, observation, and staff interview.