Failure to Provide and Document Incontinent Care
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who required assistance with personal care. On two consecutive days, a complaint was received that the resident had not been changed, resulting in a strong odor of urine and saturated briefs and bedding. Review of assignment sheets showed limited staffing during the relevant shifts, and documentation for incontinent care was either missing or indicated that care was not provided. Specifically, there was no record of incontinence care being performed on several shifts, and on one occasion, the resident was documented as refusing care without any evidence that the nurse was notified or that education was provided to the resident. Medical record review confirmed that the resident needed thorough skin care for each incontinent episode, as recommended by a nurse practitioner treating the resident's wounds. The Director of Nursing, in the presence of the Nursing Home Administrator, acknowledged concerns regarding the lack of documentation and agreed that if staff did not sign off on the task, it was considered not done. The findings were based on both documentation review and interviews, confirming that incontinent care was not consistently provided or properly documented for the resident in question.