Failure to Provide Timely Incontinence Care Due to Staffing and Gender Preference Constraints
Penalty
Summary
The facility failed to provide adequate and timely incontinence care to a resident who was continent/incontinent of bladder. The resident, admitted with diagnoses including muscle weakness, need for personal care assistance, and morbid obesity, had a care plan indicating self-care deficits and requiring assistance from two staff members for toileting and personal hygiene, with an intervention specifying that only female staff provide personal care per the resident’s request. During an observation of incontinence care at 7:52 A.M., the resident was found incontinent of a large amount of stale-smelling urine that had soaked through two incontinence briefs and linens, necessitating a full bed change. The resident reported not having been changed since approximately 6:00 P.M. the previous evening, and the CNA providing care confirmed that the resident was heavily soiled at the start of her 6:00 A.M. shift and that there had been times when no female CNAs were available to change the resident, resulting in a lack of timely incontinence care. This deficiency was cited for failure to ensure adequate and timely incontinence care for one resident out of three observed for incontinence care, as identified through observation, interview, and record review under a complaint investigation.
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