Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, congestive heart failure, and bladder incontinence was observed to have not received timely incontinence care despite being dependent on staff for assistance. The resident was noted sitting in a reclining wheelchair with wet pants and a strong urine odor. Staff interviews and record reviews revealed that the resident had not been changed since approximately 8:00AM, and by late morning, the resident's clothing remained soiled. The resident's care plan required perineal cleaning with each incontinence episode, but this was not followed. Further observations showed that the resident was wearing two incontinence briefs, both heavily soiled, which staff stated was a common practice for this resident. The assigned CNA confirmed that no incontinence care had been provided since the start of her shift. The interim DON acknowledged that wearing two briefs was not appropriate and that the resident had gone too long without being changed or repositioned. The facility's policy required appropriate treatment and services for incontinent residents to prevent infections, but this was not adhered to in the resident's care.