F0690

E

Failure to Provide Timely Incontinence Care Resulting in Prolonged Wetness

Dallas, Texas Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

A cognitively intact female resident with a history of brain bleed, back pain, type 2 diabetes, bladder incontinence, and current antibiotic therapy for UTIs was admitted to the facility and returned from the hospital via ambulance late at night. Her care plan documented bladder incontinence with an intervention to check as required for incontinence. The resident reported she received incontinence care around 4–5 AM after returning around midnight, and by late morning she remained in a wet brief, stating she had not been changed again and that this was causing her distress. She also stated she was usually out of the facility in the mornings for therapy at another location and was present that morning only because she had just been discharged from the hospital.

By early afternoon observation, the resident was still unchanged, indicating she had been left in the same brief for more than seven hours. The resident reported she had activated her call light about an hour earlier, a nurse had responded and said an aide would assist, but no one returned to provide incontinence care. The CNA assigned to the resident acknowledged she had not yet checked on the resident since coming on duty at 6 AM, stating she was busy and believed the resident had just returned from the hospital. The RN assigned to the resident stated CNAs were expected to make rounds every 2–3 hours and residents should be changed every 2 hours or when wet or soiled, and the DON confirmed the expectation that residents be checked every 2 hours and never left wet for more than 4 hours, noting that nurses could also provide incontinence care when CNAs were busy. The facility’s Abuse & Neglect policy defined neglect as deprivation of goods and services that would cause emotional distress.