Failure to Provide Timely Incontinent Care and Documentation
Penalty
Summary
The facility failed to provide timely and adequate incontinent care for four out of five sampled residents, as evidenced by observations, interviews, and record reviews. Multiple residents were observed lying in bed waiting for incontinent care, with several reporting that they often waited for extended periods before being changed. Documentation logs revealed that these residents were approached for incontinent product changes as infrequently as once in an eight-hour, twelve-hour, or even twenty-four-hour period on multiple occasions. This was inconsistent with the facility's own policies and care plans, which required residents to be checked and changed every two hours or as needed. The residents involved had significant medical histories, including diagnoses such as Parkinson's disease, diabetes mellitus, hypertension, dementia, acute kidney failure, urinary tract infection, chronic kidney disease, and mobility impairments. Their care plans specified that they were incontinent and required staff assistance with toileting and hygiene, with interventions to ensure they remained clean, dry, and odor-free. There was no documentation indicating that any of these residents refused care, nor were there care plans addressing refusal behaviors. Progress notes also lacked any record of refusals, further supporting that the care was not provided as required. Interviews with staff, including CNAs, RNs, and facility management, confirmed that the expectation was for incontinent care to be provided and documented every two hours. However, some CNAs admitted to not documenting checks if the resident did not need to be changed, contrary to facility policy. The facility's policies on documentation, ADLs, dignity, and incontinence care all emphasized the importance of timely, complete, and accurate care and record-keeping. Despite these policies, the documented frequency of care provided did not meet the established standards, resulting in residents not receiving appropriate incontinent care.