Failure to Provide Timely Incontinence Care to a Dependent Resident
Penalty
Summary
Surveyors identified a failure to provide required assistance with ADLs, specifically incontinence care, to a dependent resident. On 1/28/2026 at 12:30 p.m., the surveyor, along with a rehabilitation aide and a CNA, observed the resident in bed wearing a urine-soaked incontinence brief (depend) that was so saturated it began to separate when staff attempted to remove it. The resident’s admission record documented diagnoses including Alzheimer’s disease, encounter for palliative care, and dysphagia, and the resident was described by staff as dependent on all care from staff. During interviews, the CNA assigned to the resident stated she performs resident rounds before breakfast and after lunch but had not yet made rounds for this resident because the rehabilitation aide had made rounds earlier. The rehabilitation aide reported that she had provided incontinence care to the resident only once at 7:30 a.m. that day and that resident rounds are supposed to occur every two hours and as needed, with her role limited to assisting with morning care. The DON stated she expects CNAs and nursing staff to conduct rounds every two hours and as needed, especially for dependent residents. The resident’s care plan, dated 11/7/2024, included an intervention to keep the skin clean and dry and to perform prompt toileting/incontinence care, and the facility’s August 2024 ADL policy required that dependent residents receive regular assistance with ADLs such as toileting, with all nursing staff and CNAs responsible for direct care.
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