F0684

D

Failure to Provide Timely Incontinence Care per Care Plan and Policy

Manteca, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinence care in accordance with professional standards and the resident’s care plan for one resident with paraplegia and complete bowel and bladder incontinence. The resident reported around midday that she had not received care since 6:30 AM and had requested to be cleaned and dressed at 11 AM. During observation, her incontinence brief showed a blue line indicating wetness and appeared heavily saturated with urine. The resident stated she would be unable to go to the dining room for lunch because she had not been cleaned and expressed concern about her risk for urinary tract infection if she was not changed when needed.

CNA 1 stated she attempted to provide care at 7 AM, but the resident asked her to return at 11 AM. CNA 1 did not provide care at 11 AM because she went to lunch and stated that CNA 2 had changed the resident instead. CNA 2 later stated he did not provide care to the resident at 11 AM or at any other time during the shift. LN 2 stated her expectation was that the resident would receive timely incontinence care or that CNAs would inform her if they were unable to provide care. The DON stated residents were usually changed every two hours, that refusals would be care planned, and that CNAs should continue to attempt care and notify the nurse if refusals continued. The resident’s care plan documented that she was always bowel and bladder incontinent, with goals to remain free from skin breakdown due to incontinence and interventions including cleaning the perineal area with each incontinence episode, checking every 2–3 hours and as required, and monitoring for signs and symptoms of UTI. The facility’s incontinence care policy required timely, appropriate, individualized care at routine intervals per the care plan and as requested by the resident.