Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting and incontinence care, resulting in residents remaining wet or soiled for extended periods. One resident reported being wet and stated that staff would not change her brief, adding that she had not been changed since being placed in a reclining chair for breakfast. When a CNA later provided incontinence care, the resident was found with a saturated panty liner and a saturated brief. The CNA stated that incontinence care was provided to assigned residents only twice per shift, once at the beginning and once at the end of the shift, which did not align with the facility’s policy or the ADON’s expectations for checks every 2–3 hours. Another resident’s call light was observed to be on for an extended period before staff responded. When asked, the resident indicated a need for a brief change. A CNA entered the room, turned off the call light, exited, and only later informed another CNA that the resident needed incontinence care, which was not provided until several minutes afterward. A third resident stated she needed to use the bathroom and had been holding her urine while waiting for staff. After being taken to her room, the CNA initially checked only the front of the brief and stated it was dry; when asked to check the back, the brief was found to be saturated with urine. This CNA also reported providing incontinence care only at the beginning and end of the shift. The ADON and the written incontinence care policy both indicated that incontinent residents should be checked and changed every 2–3 hours or every two hours, more often for heavy wetters, which contrasted with the observed practices.
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