Failure to Provide Incontinence Care per Care Plan
Penalty
Summary
The facility failed to provide incontinence care in accordance with the care plan for one resident who was dependent on staff for toileting due to paraplegia and a C5-C7 spinal cord injury. The resident's care plan specified total assistance from two staff members for toileting and incontinence care as needed, due to the resident's self-care performance deficit and risk for skin integrity impairment. Facility policy required that residents unable to perform activities of daily living independently receive appropriate support, including elimination and toileting, in accordance with their care plan. On observation, a CNA verified that the resident's incontinence pad and brief were saturated and showed a light brown ring of dried urine, indicating the resident had not been changed throughout the night. The CNA confirmed the resident had not been changed since the start of her shift. The DON acknowledged that the care plan was not followed, as the resident did not receive the required incontinence care overnight. The resident was cognitively intact and dependent on staff for toileting at the time of the deficiency.