Failure to Provide Timely Incontinence Care for Two Residents
Penalty
Summary
Facility staff failed to provide timely incontinence care for two residents who were unable to perform activities of daily living independently. One resident, with diagnoses including quadriplegia and spinal cord compression, was assessed as cognitively intact and frequently incontinent of bowel and bladder. On the early morning in question, the resident was found soaked at the start of the day shift, indicating that incontinence care had not been provided during the previous shift. The resident did not recall receiving care during the night and reported sleeping through most of it. Staff interviews and facility documentation confirmed that the resident was not checked or changed prior to the day shift, despite care plan interventions requiring frequent checks and changes. Another resident, with a history of COPD, diabetes, BPH, congestive heart failure, and dementia, was also assessed as cognitively intact and frequently incontinent. This resident was found with a heavily soiled brief and wet bed linens at the start of the day shift. The resident's roommate reported that the assigned CNA did not provide a brief change during the last round of the shift. Staff interviews and facility investigation corroborated that incontinence care was not provided as required by the resident's care plan, which called for frequent checks and changes. In both cases, the lack of timely incontinence care was identified through staff and resident interviews, review of facility documentation, and clinical record review. The findings were discussed with facility leadership, and the facility's own investigation supported the evidence of failure to provide care as outlined in the residents' care plans. No skin issues were identified for either resident following the incidents.