Failure to Provide Timely Incontinent Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living, including toileting hygiene, did not receive timely incontinent care. The resident, who had a history of cerebral infarction, type 2 diabetes, major depressive disorder, and hypertension, was observed on the morning of 10/29/2025 with saturated linens, a wet gown, and macerated skin on her buttocks. The care plan required staff to check and assist the resident every two hours and clean the perineal area after each incontinence episode. However, the resident reported not being changed since the previous night, and staff confirmed that the resident had not received care during the night shift as required. Staff interviews revealed that nurse aides were expected to round every two hours to ensure residents were clean and dry, but this did not occur for the resident in question. The CNA who provided care that morning stated it was her first round with the resident and acknowledged the resident was soaking wet and had not been changed since the previous night. The DON and Administrator both confirmed that incontinent care should be performed every two hours, but were unaware that the resident had not received timely care. Facility policy also required regular perineal care to promote cleanliness and prevent infection.