Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was fully dependent on staff for activities of daily living, including incontinence care, was not provided timely assistance. The resident, who had multiple diagnoses such as hemiplegia, seizure disorder, anxiety disorder, depression, bipolar disorder, and cerebral palsy, was found to be soaked with urine through her brief, draw sheet, and bed sheets. The care plan for this resident required staff to check and assist with toileting every two hours, but on the day in question, the resident had not been changed for at least seven hours, with the last incontinence care provided around 4:00 AM and the next care not occurring until after 11:00 AM. Observations and interviews revealed that the resident's room had a strong smell of urine, and the resident herself reported being wet and needing to be changed. Staff interviews confirmed that the resident was fully incontinent and dependent on staff for care, and that it was not normal for her to be found in such a condition. The CNA assigned to the resident admitted to not having checked on her yet during the shift, citing difficulties in performing two-hourly rounds due to workload and assignment changes. The RN and ADON both stated that staff were expected to check on residents at least every two hours, and acknowledged that the resident should have been checked and changed more frequently. Facility policy required perineal care to be provided during routine baths and as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. Despite this, the resident was left in urine-soaked bedding for an extended period, which was confirmed by multiple staff members and direct observation. No skin issues were noted at the time, but staff recognized that such lapses in care placed the resident at risk for adverse outcomes.