Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to timely provide incontinence care, toileting-related ADL assistance, and repositioning for three dependent residents. One resident, admitted with diagnoses including hypertension and pain and assessed as moderately cognitively impaired, required substantial/maximal assistance with toileting hygiene, personal hygiene, bathing, and meal setup, and had a care plan directing incontinence checks at least every two hours during the day. This resident was observed in bed from early morning through mid-morning without evidence of incontinence checks; at 10:50 AM, staff found the resident soiled with loose stool covering the pubic area. The resident’s fingernails were noted to have soil underneath, and there was no prior observed incontinence care before that time. Another resident, with diagnoses including adult failure to thrive, heart disease, and Alzheimer’s disease, and severely impaired cognition, required substantial/maximal assistance for toileting hygiene and was dependent for bathing, dressing, and personal hygiene, with partial assistance needed for bed mobility and meal setup. This resident was observed in bed with the breakfast tray positioned at mouth and nose level, unable to respond meaningfully, with a urine odor present; the bed controls were out of reach, and the LPN did not adjust the resident’s position when questioned. Later, staff found a visibly urine-soiled brief, and the CNA reported this was the first incontinence care provided to these residents since the start of the 7 AM shift. A third resident, admitted with diagnoses including left-sided paralysis, stroke, and malnutrition, had a care plan indicating incontinence of bowel and bladder, need for assistance with ADLs, and total dependence on staff for repositioning in bed at least every two hours and as necessary. This resident was repeatedly observed supine in bed with the head of the bed elevated 30–45 degrees, eyes closed, and legs elevated with heel boots, from late morning through mid-afternoon. Across multiple observations, the resident’s position did not change, including when the head was noted to be off the right side of the pillow. The DON later stated that aides may prioritize timing of care based on resident needs and reported that rounds had been completed initially and between 9:00 and 9:30 AM, but the observed positions of the residents had not changed. Facility policy on toileting stated that when a resident indicates verbally or non-verbally a need to use the bathroom, staff should promptly assist, but the observations showed delays in incontinence care and lack of timely repositioning for these dependent residents.
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