Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, Lennox-Gastaut Syndrome, epilepsy, autistic disorder, and incontinence of urine and bowel was not provided timely incontinence care. The resident's care plan required frequent checks for incontinence and perineal care after each episode. On the day of observation, the resident had not been changed since getting up in the morning, resulting in a saturated incontinence brief, soiled clothing, and a strong urine odor. Staff confirmed that the resident had not been checked or changed for several hours, despite facility policy and care plan directives to check at least every two hours. Interviews with staff and the resident's family member confirmed the lapse in care, with staff acknowledging the resident's high risk for skin breakdown due to incontinence and inability to reposition independently. The facility's policy on pressure injury assessment and treatment also required prompt cleaning of soiled skin, but there was no specific incontinence care policy in place at the time of the incident. The deficiency was identified through direct observation, interviews, and record review.