Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of bladder and bowel did not receive timely incontinence care. The resident, a cognitively intact female with multiple diagnoses including autonomic neuropathy, depression, hypertension, atrial fibrillation, and chronic heart failure, reported not having her incontinence brief changed all morning. She also stated her call light had not worked for two months, and she relied on a bell to alert staff. Record review confirmed her incontinence status, and interviews with staff revealed that the certified nursing assistant (CNA) assigned to her had not changed her since the start of the shift at 6:00am, despite facility policy and staff expectations that incontinence care be provided every two hours or as needed. The CNA reported being responsible for 16 residents and having multiple competing duties, which contributed to the delay in providing care. Both the licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that the facility's expectation was for incontinence care to be provided every two hours or when requested, and that delays could result in skin breakdown, depression, or infection. Facility policy required perineal/incontinent care after each episode of incontinence. The failure to provide timely care was directly observed and confirmed through interviews and record review.