Failure to Provide Timely Incontinent Care per Care Plan and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care according to the resident’s care plan and facility policy for one dependent resident. The resident had diagnoses including schizophrenia, depression, anxiety, adult failure to thrive, and muscle weakness, and was care planned on 1/21/26 as needing assistance with all ADLs due to cognitive and physical deficits, having urinary incontinence, and a pressure ulcer. The care plan directed staff to check the resident for incontinence every two hours and as needed, assist with toileting, and provide resident-specific toileting upon rising, after meals, at bedtime, and at five specified times each day (8:00 AM, 10:30 AM, 2:00 PM, 6:30 PM, and 9:00 PM). A Significant Change in Condition MDS assessment documented that the resident had poor memory recall, was always incontinent of bowel and bladder, and was dependent for all ADLs including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting hygiene. On 2/21/26 at approximately 10:30 AM, a family member arrived and found the resident saturated in urine and feces and reported this to the charge nurse (LPN). During interview, the 7AM–3PM NA stated incontinent care should be provided every two hours and as needed for incontinent residents but could not recall specific details of the incident. The 7AM–3PM charge nurse later reported that, on the date of the incident, the family member told her the resident was soaked in urine; when the LPN asked the NA when care was last provided, the NA stated she had been busy and had not provided incontinent care since first rounds at the beginning of the shift at 7:00 AM, nearly five hours earlier. The DON stated she was not informed of the concern and explained that incontinent care or monitoring should occur during first rounds and at least four times per shift, including at the end of each shift, and that it is the charge nurse’s responsibility to ensure NAs provide care per policy. The facility’s urinary continence and incontinence policy directed that management of incontinence follow relevant clinical guidelines and that a check-and-change strategy be used at regular intervals to maintain dignity, comfort, and skin protection, which was not followed in this case.
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