Failure to Provide Timely Incontinence Care Due to Staff Communication Breakdown
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was dependent on staff for assistance with activities of daily living (ADLs). The resident, who had intact cognition and required substantial to moderate assistance for toileting and personal hygiene, reported turning on their call light at approximately 7:00 AM to request incontinence care. When a CNA responded, the resident was told that breakfast trays were about to be distributed and that the assigned CNA would be notified. However, the assigned CNA was not informed of the resident's need for care at that time. Subsequently, the resident received breakfast and, after waiting for an unspecified period, activated the call light again. This time, an LPN responded and was told by the resident that incontinence care was still needed. The LPN relayed to the resident that the assigned CNA would be there soon, but did not directly communicate the resident's request to the CNA. Interviews with staff revealed that the assigned CNA was unaware of the resident's need for incontinence care until much later and did not provide care until approximately 10:15 AM, over three hours after the initial request. Facility policy required prompt assistance with ADLs, including elimination needs, and staff interviews confirmed that the expectation was for care to be provided immediately or for another staff member to assist if the assigned CNA was unavailable. The delay in care resulted from a breakdown in communication among staff members, with multiple staff failing to notify the assigned CNA or provide care themselves, leaving the resident in a soiled brief for an extended period.