Failure to Provide Timely Incontinent Care and Linen Changes
Penalty
Summary
A male resident with dementia, type 2 diabetes, and a psychotic disorder was admitted to the facility and assessed as requiring varying levels of assistance with activities of daily living, including partial assistance with personal hygiene and supervision with toileting. The resident was noted to be occasionally incontinent of bladder and always continent of bowel. Despite care plan interventions for supervision and assistance, the resident was observed on multiple occasions to be left in visibly wet clothing and soiled linens, with a strong odor of ammonia present in his room and on his person. On two separate days, the resident was seen sitting in a wheelchair and lying in bed with wet clothing and soiled sheets, with observations of yellow and brown stains and persistent strong odors. Staff interviews revealed inconsistencies in rounding practices, with one CNA stating she rounded every 30 minutes to 2 hours, while another CNA delayed rounding due to other duties and reported that the resident refused care when offered. The resident himself was unable to recall when staff last checked on him and believed he was dry, despite evidence to the contrary. Facility policy required incontinent residents to be identified, assessed, and provided with appropriate treatment and services, including regular checks for wet or soiled linens and provision of perineal care. Interviews with nursing staff and administration confirmed that CNAs were expected to round at least every two hours and address incontinent care needs, but observations and staff statements indicated these expectations were not consistently met for this resident.