Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide timely incontinence care for four residents who were dependent on staff for activities of daily living, specifically toileting and hygiene. Observations and interviews revealed that residents were left in soiled briefs and clothing for extended periods, sometimes for over nine hours, without being checked or changed. Staff members, including CNAs, confirmed that due to insufficient staffing, residents were not checked or changed as frequently as required, with some residents only receiving incontinence care twice during a 12-hour shift. Residents were observed with saturated briefs, wet bedding, and in some cases, dried stool and urine on their skin, resulting in foul odors and visible skin irritation. One resident with hemiplegia and dementia was placed in a chair at 5:00 A.M. and was not checked or changed until 2:45 P.M., at which time staff confirmed the resident's brief was heavily saturated and the resident had an odor of urine. Another resident, who was cognitively intact but had bilateral leg amputations and was always incontinent, reported to surveyors that she was left soaked in urine and that staff did not respond promptly to her requests for assistance. Staff confirmed that this resident had not been checked or changed for several hours, and her brief and bed pad were saturated with urine. A third resident, with hemiplegia and moderate cognitive impairment, was found with a saturated brief containing urine and stool, with dried stool on the skin and deep red, sensitive areas on the body from prolonged exposure. Family members of a fourth resident reported that staff failed to provide incontinence care despite repeated requests, resulting in the family having to change the resident themselves after waiting several hours. The facility's own policy required residents to be checked and changed every two to three hours, but this standard was not met for the residents reviewed.