Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a male resident with severe cognitive impairment and total dependence on staff for toileting and hygiene. On the observed date, the resident was not provided with incontinence care for approximately 4.5 hours, from 9:30 a.m. until 1:45 p.m., despite being always incontinent of bowel and bladder and requiring substantial assistance for all activities of daily living. During this period, the resident was observed in various locations throughout the facility, including the dining room and common areas, but was not checked or changed by staff. When care was finally provided, the resident was found to have a wet brief and a recent bowel movement, though no skin breakdown was noted at that time. Interviews with CNAs and facility leadership confirmed that staff were expected to check residents for incontinence at least every two hours, but this was not consistently done. Staff reported relying on spot checks or passing by residents rather than following a scheduled rounding protocol. The facility did not have a specific policy on perineal or incontinence care, and the existing Activities of Daily Living policy only generally referenced providing necessary assistance. The lack of timely care placed the resident at risk for skin breakdown and infection, as acknowledged by the DON.