Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in accordance with its Guidelines for Incontinence Care and residents’ care plans for three dependent residents. One resident with mild cognitive impairment and documented dependence on toileting hygiene reported in the morning that she thought she was wet; later that morning she was observed wearing a dark, blackish incontinent brief with a strong odor of urine and feces. The CNA assigned stated she had been on duty since 7:00 AM, had been passing meal trays, and had not yet changed the resident. The following day, the same resident reported she had not yet been changed by mid-morning; a CNA then stated she had just been pulled from another floor and had not yet changed the resident. When incontinence care was finally provided, the resident’s brief was moderately wet with urine. The resident’s restorative care plan required checks every two hours and as needed, with perineal cleansing and clothing changes after incontinence episodes. Another resident with severe cognitive impairment and dependence on toileting hygiene was reported by her fiancé to have received no checks between his arrival in the morning and early afternoon. He stated that by early afternoon the resident’s incontinent brief was heavily soaked with bowel movement and was smelly, and that staff changed her at that time. A third resident, cognitively intact but dependent on toileting hygiene, reported waiting to be changed and stated she had last been changed in the early morning by night staff. After the resident activated her call light, a CNA responded and found the resident with a moderately wet, brownish-colored incontinent brief; the CNA stated she had just been moved from another floor, had not received report, and that no nursing assistant had been assigned to that resident. The DON stated that staff are supposed to change incontinent residents every two hours and as needed, and the facility’s undated Guidelines for Incontinence Care require at least every two-hour checks and assistance with cleansing after incontinence episodes, which was not followed in these cases.
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