Failure to Provide Timely Incontinent Care and Personal Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and necessary services to maintain personal hygiene for one resident who was totally dependent on staff for toileting and was always incontinent of bladder and bowel. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and multiple neurologic and medical conditions including aphasia, hemiplegia/hemiparesis, and a history of severe sepsis, had a care plan intervention for bladder and bowel incontinence that included checking and changing as required. During an observation of incontinent care in the afternoon, surveyors noted a strong odor of urine when the resident’s brief was removed, and the brief was heavily soiled with urine, although the skin remained intact without redness or rash. CNA A reported that the last incontinent care provided to this resident had been at 10:00 a.m., and that she usually checked and changed the resident every two hours. CNA A stated she had been assisting residents in the dining room with meals and then went on break, telling the nurse but not checking the resident for incontinence before leaving and not arranging specific coverage with another CNA. She did not answer when asked why she failed to check the resident before her break and said she did not know who was supposed to relieve her. RN C stated she did not recall being told that CNA A was going on break and did not know which CNA was covering. The DON stated residents should be checked for incontinence every two hours, that failure to do so placed residents at risk, and that the nurse in charge is responsible for ensuring timely incontinent care, with CNAs expected to notify other CNAs and the charge nurse before going on break and to check residents’ needs, including incontinence, prior to leaving. Facility documents included an incontinence care policy and a peri-care training form, but the DON reported there was no specific policy on female incontinence.
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