Failure to Provide Timely Incontinence Care After Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident, resulting in the resident remaining in soiled clothing for one hour and 33 minutes after staff were notified. The resident had diagnoses including COPD, muscle weakness, and dementia, with an MDS BIMS score of 7 indicating severely impaired cognition. The resident’s care plan identified bowel and bladder incontinence related to impaired mobility and dementia, with a goal to remain free from skin breakdown due to incontinence and interventions specifying incontinence brief use with changes every two hours and as needed. On the day of the incident, the resident was observed at 11:55 AM with soiled pants as she was assisted into her room, and a staff member used an earpiece to request assistance for a brief change. Subsequent continuous observations showed multiple staff entries into and past the resident’s room without providing the needed incontinence care. At 12:02 PM, a CNA entered only to ask about meal location and then exited without checking or changing the brief. At 12:21 PM, another CNA walked by the room without entering. At 12:55 PM, the resident reported she believed her brief had been changed, then checked and realized it had not. At 1:23 PM, a CNA entered only to deliver a meal tray and left, and another staff member entered to check the activities calendar and exited without addressing incontinence needs. At 1:28 PM, staff brought the roommate into the room and a CNA brought in a Hoyer lift and closed the door; by 1:38 PM, CNAs exited the room and indicated the resident was “all good,” and at 1:39 PM the resident was observed in a recliner with different pants, indicating the change had finally occurred. Interviews confirmed that rounding was expected every one to two hours, that the resident commonly had a wet brief after activities, and that activities staff radioed nursing when a brief change was needed, but the incontinence care for this resident was not provided in a timely manner after the initial notification.
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