Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide timely incontinence care for one resident who was observed continuously from 10:07 a.m. to 5:30 p.m. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken to her room for incontinence checks or care. Staff interviews confirmed that the standard practice is to check incontinent residents at least every two hours, with some staff indicating even more frequent checks for residents unable to communicate their needs. However, the assigned CNA admitted that, despite walking by and checking in on the resident, she did not take the resident to her room for incontinence care at any time during her shift. The resident's most recent assessment indicated severe cognitive impairment, inability to communicate needs effectively, and total dependence on staff for toileting. Facility management and staff acknowledged that extended periods without incontinence care could lead to skin breakdown and emotional distress. A review of the facility's urinary elimination policy did not specify the required frequency for incontinence care, and no additional relevant documentation was provided prior to the survey exit.