Failure to Provide Timely Incontinence Rounding Resulting in Prolonged Urine Saturation
Penalty
Summary
A cognitively intact resident with hemiplegia, hemiparesis, acute kidney failure, and severe physical impairment was care planned and assessed as always incontinent of bowel and bladder, dependent on two staff for toileting, hygiene, and incontinence care, with an expectation of two-hour incontinence rounding to keep the resident clean and dry. On the date in question, a nurse aide assigned to the resident from 7:00 AM to 11:00 PM transferred the resident to a wheelchair between 2:00 PM and 3:00 PM and did not check the resident’s incontinence status again until approximately 8:00 PM, despite the resident’s care plan and facility expectations for two-hour checks. During this period, the resident remained in the wheelchair, including through the supper meal, and later reported that his brief and pants were soaked with urine and that he felt bad having to sit in wet pants. The resident stated he did not inform staff he had urinated because he did not want to bother them. When the nurse aide finally responded around 8:00 PM after the resident activated his call light, she found the resident’s brief, pants, wheelchair seat, and lift pad saturated with urine. Another nurse, who began her shift at 7:00 PM and had not checked on the resident prior to responding to the resident yelling for help at approximately 8:00 PM, also observed that the resident’s pants, wheelchair seat, and lift pad were saturated to the extent that a mechanical lift could not be safely used, requiring four staff to assist the resident back to bed. A second nurse aide, who had left at 3:00 PM, confirmed that the assigned aide was responsible for two-hour incontinence rounding and stated the resident was not consistently able to notify staff when he needed to be changed and was dependent on staff for incontinence rounding. The DON and Administrator both stated that residents were to receive incontinence care every two hours and should not be left sitting in incontinence, confirming that the resident should have received incontinence care between 2:00 PM and 8:00 PM.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.