Failure to Provide Ordered and As-Needed Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was completed as ordered and as needed for residents who were dependent on staff for activities of daily living. One resident, admitted with diagnoses including spastic hemiplegia, osteoarthritis, and hypertension, had a care plan indicating episodes of incontinence related to aging, with interventions to check the resident every two hours, assist with toileting as needed, and provide peri-care after each incontinent episode. A quarterly MDS showed this resident had impaired cognition, was dependent on staff for all ADLs, used an electric wheelchair, and experienced frequent bowel and bladder incontinence. Review of incontinence sheets over nearly a month showed staff changed this resident on average twice a day, and the resident reported having to wait a long time to be changed, sometimes stating staff did not show up, though she could not provide specific times or dates. Another resident, admitted with diagnoses including type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts, had a quarterly MDS indicating intact cognition, need for substantial assistance with bed mobility and transfers, use of an electric wheelchair, and frequent bowel and bladder incontinence. The care plan documented that this resident had episodes of incontinence and depended on staff for assistance, with interventions including application of skin moisturizers/barrier creams as needed and provision of toileting/incontinent care as needed. Incontinence sheets for this resident over the same time frame also showed an average of two changes per day. Staff interviews, including with an LPN and a CNA, indicated that when staffing was short, residents experienced longer wait times to be changed. This resident reported being left in a soiled brief for hours throughout the week. The DON confirmed there was a lack of documentation indicating that incontinence care was completed as ordered and as needed.
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