Failure to Provide Timely Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care to two residents. One resident, who was severely cognitively impaired, totally dependent on staff for all self-care and mobility, and exhibited continuous inattention and disorganized thinking, was observed sitting in various locations for approximately six hours without receiving incontinence care. During this period, the resident was moved between the dining room, hallway, therapy room, and back to the dining room before being transferred to their room for wound care. Incontinence care was not provided until after the wound care was completed, at which point staff confirmed the resident's brief was wet. Another resident, who had an indwelling catheter and was frequently incontinent of bowel, reported not receiving timely assistance with toileting. The resident had to call the facility to request help after their call light was not answered for about an hour. Documentation and interviews confirmed that the resident's request for a bedpan was delayed, and pericare was not performed. The same staff member was involved in both reported incidents, and the concern had been previously voiced by the resident.