Failure to Provide Timely Incontinence Care and Document Refusals
Penalty
Summary
The facility failed to provide adequate and timely incontinence care for two residents who were dependent on staff for activities of daily living. One resident with diagnoses including paranoid schizophrenia and anxiety reported being left in a saturated brief for an entire day shift, with no incontinence care provided by the assigned CNA. The resident stated he did not refuse care, and this was corroborated by the night shift CNA, who found the resident and his bedding soaked with urine and provided immediate care. The day shift CNA admitted she did not know the resident was incontinent and did not receive a report about his needs, leading to a lack of care throughout her shift. She later reported to the ADON that the resident refused care, but this was not documented during the shift, and no interventions or escalation were attempted at the time. Another resident with dementia and anxiety, who was known to be resistant to care, was found in bed without clothes or an incontinence brief, lying on saturated sheets and pads. The resident stated she removed her soiled clothing and brief due to being wet with urine. The night shift CNA reported that the resident refused care and threw soiled items at her, but there was no documentation of the refusal or of any interventions attempted to provide incontinence care overnight. The day shift CNA did not provide care in the morning, stating she did not want to wake the resident and was unaware of the resident's condition or lack of clothing. When care was finally provided, the resident was cooperative and received incontinence care and clean linens. Facility policies required CNAs to provide incontinence care every two hours and as needed, and to document refusals of care, including interventions attempted and notification of the charge nurse and provider. In both cases, staff failed to follow these policies, resulting in residents remaining in soiled conditions for extended periods without appropriate documentation or escalation. There was also a lack of communication during shift changes, leading to gaps in care and failure to meet residents' needs.