Failure to Provide Timely and Adequate Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically timely incontinence care, for two residents who were dependent on staff for these needs. Both residents had severe cognitive impairment, hemiplegia or hemiparesis, and were largely confined to bed, requiring substantial to maximal assistance for toileting and hygiene. Their care plans included interventions such as scheduled toileting, use of briefs, frequent turning and repositioning, application of barrier lotion, and regular skin inspections to prevent skin breakdown and maintain hygiene. On the day of observation, one resident was found in bed with soaked linens and was unable to recall when her brief was last changed. The other resident reported her brief had last been changed the previous night and stated she was wet. During incontinence care, both residents were found to be heavily soaked in urine, with one also having a bowel movement. The CNA providing care did not cleanse the perineal area for either resident, only cleaning the abdominal folds and buttocks. Additionally, the CNA did not change gloves or perform hand hygiene between cleaning different areas after a bowel movement. Interviews with the CNA, LVN, ADON, and DON revealed that staff were expected to perform incontinence rounds every two hours and as needed, but the CNA admitted to not following this schedule due to being busy with other residents. The LVN and nursing leadership confirmed their responsibility to monitor CNA rounds, but could not specify when rounds were last completed. Training records indicated that while staff had received instruction on perineal care, the training did not specifically address the requirement for incontinence care every two hours. The facility's policy required perineal care in accordance with standard practice to prevent skin breakdown and infection.