Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were dependent on staff for these activities. One resident, admitted with muscle weakness and a need for personal care assistance, was care planned and assessed as incontinent of bowel and bladder and dependent on staff for toileting, with intact cognition. This resident reported being left soiled for several hours on multiple occasions, including one night when her call light for incontinence care remained on from 1:00 A.M. to 3:45 A.M. without staff response, and another night when she was not changed from approximately 5:00 P.M. until about 7:00 A.M. the next morning. She stated that when she requested help during the night, an aide told her she could not provide incontinence care due to a lack of linens, and the resident remained incontinent until the day shift provided care. A CNA confirmed that on a morning shift she found this resident saturated in urine and requiring a full bed change, and also stated she had frequently observed residents soiled at the start of her 7:00 A.M. shifts and that management was aware. Another resident, admitted with a history of stroke with left-sided weakness and muscle weakness, was also documented as cognitively intact, incontinent of bowel and bladder, and dependent on staff for toileting, with a care plan intervention to provide incontinence care after each episode. This resident, who served as resident council president, reported that multiple residents had complained about not receiving timely toileting assistance and remaining soiled for long periods. On a specific evening and night, this resident reported not being changed, and a CNA who arrived for the day shift stated that both this resident and another had been left incontinent overnight and required complete bed changes due to being heavily soiled. An LPN acknowledged being made aware that residents had not been changed during the evening and night shift, and a regional RN and the administrator confirmed that the CNA assigned to these residents during that time had failed to check and change residents on her assignment. Facility policy required staff to perform ADL care, including personal hygiene and toileting, but the observed and reported care did not meet these expectations.
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