Failure to Provide Timely and Appropriate Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of altered mental status, muscle weakness, and colon cancer, who was always incontinent of bowel and urine and required extensive assistance with activities of daily living, did not receive incontinence care according to their care plan and professional standards. The care plan specified that the resident should be checked and changed every two to four hours and as needed, but documentation showed that incontinence care was provided less frequently, with some days showing only one or two changes and some days with no documented care at all. On one occasion, the resident was observed in the dining room for several hours with a strong odor of bowel incontinence, and was later found with a saturated brief and a non-disposable incontinence pad inside the brief, along with redness to the buttocks. Staff interviews confirmed that the resident was consistently incontinent and required frequent care, but there was no evidence of interdisciplinary discussions or updates to the care plan to address the resident's chronic loose stools and increasing incontinence needs. The Director of Nursing acknowledged that the care plan needed updating and that the use of a non-disposable pad inside the brief was inappropriate. Documentation of incontinence care was inconsistent and did not reflect the frequency required by the resident's condition or the facility's policy.