Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The facility failed to follow its Incontinence Care Guidelines by not providing timely incontinence care to residents who were dependent on staff for toileting hygiene. Three residents, all dependent on staff for incontinence care as documented in their Minimum Data Set (MDS) assessments, experienced delays in receiving care. One resident reported being changed only at specific times and sometimes having to wait extended hours if missed by the morning shift. Another resident was observed with a soiled brief and linens after not being changed since the start of the CNA's shift, despite the facility's policy to check every two hours. The third resident also experienced delays, with staff acknowledging the need to notify the assigned CNA and the resident remaining in a wet brief for an extended period. Observations, interviews, and record reviews confirmed that staff did not consistently check and provide incontinence care every two hours as required by the facility's guidelines and individual care plans. Staff cited being occupied with other duties, such as passing meal trays, as reasons for the delays. The Director of Nursing confirmed the expectation for two-hour checks, and the facility's written guidelines also specified this standard. Despite these policies, the care provided did not meet the documented requirements for timely incontinence care for dependent residents.