Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for a resident who was dependent on staff for toileting hygiene. The resident, an older adult with schizophrenia, an unspecified mood and behavior disorder, epilepsy, and severe cognitive impairment (BIMS score 0/15), was care planned for ADL self-care deficits requiring substantial supervision and encouragement due to frequent refusal of care. During continuous observation on 2/24/26 from 9:20 a.m. to 11:45 a.m. and again from 11:46 a.m. to 12:18 p.m., the resident remained in bed and no direct care staff were observed entering the room to offer incontinence care. An activities staff member briefly checked the room at 9:50 a.m. but left when the resident was sleeping, and a hospice social worker entered at 10:49 a.m. only to talk with the resident. At 12:07 p.m., a CNA entered the room and provided incontinence care, changing a urine-soaked brief and soiled bed linens. The CNA reported she believed the resident was last changed before her shift began at about 6:00 a.m., when hospice staff would have showered him, and acknowledged she had not checked him for incontinence since her shift started. This meant the resident had not received incontinence care for over six hours. The CNA further stated the resident often refused care, removed his own briefs, urinated in bed and on the floor, and lay in urine-soaked sheets, which she was responsible for changing. Nursing progress notes from prior dates documented episodes of the resident urinating on the floor and being found in bed with stool on the floor and urine-soaked linens and clothing. Multiple CNAs, an RN, the LPN, the DON, and the NHA all stated that dependent residents, including this resident, were expected to be checked and changed for incontinence at least every two hours, which did not occur during the observed period.
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