Failure to Provide Timely and Thorough Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate care and services for a resident who was dependent on staff for activities of daily living, specifically incontinence care. The resident, an older adult with diagnoses including hemiplegia, hemiparesis, overactive bladder, and cognitive intactness, was care planned to be checked and changed every 2-3 hours and as needed. Observations revealed that the resident was left in soiled clothing and a heavily urine-soaked brief, and had to request to be changed. During incontinent care, CNA A did not follow proper cleaning procedures, using the same wipe for multiple areas and failing to clean the perineal area before applying a clean brief. CNA A also admitted to not being the assigned CNA for the resident and stated she was nervous, which contributed to the improper care. Interviews with staff confirmed that the resident had not received incontinence care since the night shift, and the assigned CNA (CNA B) acknowledged missing a scheduled round of care. Facility policy requires incontinence care at least every 2 hours and specifies proper perineal cleaning techniques, which were not followed. The Director of Nursing and both CNAs confirmed the expectations for care frequency and technique, but these were not met, resulting in the resident not receiving the necessary care and services as outlined in her care plan.