Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including heart failure, peripheral vascular disease, diabetes, muscle weakness, anxiety disorder, and major depressive disorder, did not receive timely incontinent care despite being dependent on staff for activities of daily living (ADLs). The resident's care plan required staff assistance with grooming, hygiene, toileting, and incontinent care as needed. Documentation and interviews revealed that the resident frequently activated her call light for assistance but was often left in urine and bowel movement for extended periods. The resident reported these incidents through a grievance form and directly to the admission coordinator, stating that the issue persisted even after the grievance was marked as resolved. During an observation and interview, the resident indicated she had been lying in urine for an hour before staff responded to her call light. Upon entering, staff found her brief and two cloth pads soaked in urine. The admission coordinator confirmed ongoing reports from the resident about delayed responses to her care needs, which were communicated in morning meetings. The Director of Nursing Services stated that the facility's expectation was for incontinent care to be provided immediately when needed, but this standard was not met in the resident's case.