Failure to Provide Timely Incontinent Care for Two Residents
Penalty
Summary
Two residents with significant medical needs did not receive timely assistance with activities of daily living, specifically incontinent care. One resident, a female with morbid obesity, diabetes, hypertension, and a need for personal care assistance, was found with a saturated and soiled incontinent brief during a head-to-toe skin assessment. She reported that she had only been changed once that day, despite requesting assistance before lunch, and expressed feeling uncared for due to being left in a dirty brief for hours. Staff interviews confirmed that the resident had not been checked or changed according to the facility's policy of every two hours, and that this lapse was not communicated between shifts. Another resident, also a female with morbid obesity, diabetes, hypertension, and a history of cerebral infarction, required total care with two staff for assistance. She reported not being changed by the morning aide and having to request help from the nurse, which was not provided in a timely manner. Upon observation, her incontinent brief, draw sheets, and air mattress were found to be soaked with urine, indicating she had not been changed for an extended period. Staff interviews corroborated that rounds for incontinent care were not performed as required, and that the resident was left in a soiled state for hours. Facility staff, including CNAs, nurses, the DON, and the administrator, acknowledged that residents should be checked and changed every two hours and as needed, regardless of their size or care needs. The facility's policy and care plans for both residents specified the need for frequent monitoring and prompt changing to maintain hygiene and prevent complications. However, direct observations, resident interviews, and staff statements revealed that these protocols were not followed, resulting in residents being left in wet and soiled briefs for prolonged periods.