F0677

D

Failure to Perform Timely Incontinence Checks and Care Over Night Shift

West Point, Iowa Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinence checks and care for a resident who was dependent on staff for toileting hygiene and had a history of bladder incontinence. The resident’s MDS showed intact cognition (BIMS 14/15), hemiplegia following a CVA affecting one upper and lower extremity, decreased mobility, and frequent bladder incontinence. The care plan identified the need for assistance with ADLs related to stroke-related weakness and balance/gait impairment, and specified that the resident required assistance of one staff member for toileting and that the peri-area should be cleaned with each incontinent episode. Facility policy required rounding on all residents approximately every two hours and at the end of each shift, including incontinence checks and peri-care or toileting as necessary.

On the evening and night in question, documentation and interviews showed that the resident was last documented as continent at approximately 3:10 PM after toileting. Around 6:30 PM, a CNA (Staff B) informed another CNA (Staff A) that both residents in the room were ready for bed. At approximately 6:38 PM, the resident used the call light to request assistance, and Staff A assisted him to his recliner per his request; during this interaction, the resident told Staff A to leave the room using profanity. Staff A then assisted the roommate before exiting. Later, at about 9:15 PM, an RN (Staff C) administered medications and asked if the resident was ready for bed; the resident declined. At 10:00 PM and again at 12:00 AM and 2:00 AM, another CNA (Staff D) reported only observing the resident in his recliner during rounds, without physically checking his incontinence brief. The POC entries at 12:33 AM and 2:33 AM showed no void documented at those times.

Around 4:00 AM, the call light report showed the resident requested assistance. Staff A stated that at this time the resident requested to go to bed, but Staff A convinced him to remain in the recliner because of the time, and instead provided a urinal. Staff A acknowledged he did not return to empty the urinal or physically check the resident’s brief, relying on the resident to use the call light if he needed changing. Staff A also did not inform the nurse or other aides that the resident had previously told him to leave the room. At approximately 6:20 AM, the POC showed the resident was incontinent, and between about 6:30 and 6:45 AM, two CNAs (Staff F and Staff G) assisted the resident up for the day and found his clothes, incontinence pad (chuck), and recliner soaked with urine, and noted he was still wearing the previous day’s clothes. Staff F reported that the resident was wearing a pull-up brief, which he could not manage independently due to hemiplegia, and that the recliner was saturated from top to bottom. Staff F and Staff G both reported a strong urine odor and confirmed that no one else had come in to toilet or change the resident during the night, and that staff had not been physically checking his brief, instead relying on visual checks and the resident’s call light use. The DON stated that the resident being upset was not a reason to avoid attempting physical check and changes, and that the CNA should have reported the resident’s refusal of care so that others could intervene.