Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care and assistance with activities of daily living to a resident who was dependent on staff for these needs. The resident, who had diagnoses including morbid obesity, major depression, anxiety, chronic pain, lymphedema, urinary retention, and chronic kidney disease stage III, was cognitively intact and required total assistance from two staff members for toileting and bed mobility. The care plan specified that the resident should be checked and changed every two to three hours and as needed, with interventions to keep the skin clean and dry due to impaired skin integrity and a history of being bedfast. On the day of the incident, the resident reported waiting to be cleaned after a bowel movement that occurred earlier in the morning and stated that she had not been checked or changed since the night shift ended. The resident activated her call light around 8:00 A.M., and a CNA responded but did not provide care at that time, stating she would return. Observation later in the morning revealed the resident remained soiled, requiring a full bed linen change and complete perineal cleansing due to an extensive bowel movement that had spread to her thighs, skin creases, and around her catheter. The CNA confirmed she had not changed the resident since starting her shift and was aware of the need for care but prioritized other residents first.