Failure to Provide Timely Incontinence and Toileting Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinence care and assistance with toileting at least every two hours for four residents who were dependent or required maximum staff assistance for ADLs. One resident with severe cognitive impairment and dependent on staff for toileting was observed ambulating in the halls with sweatpants visibly wet in the buttocks, groin, and upper thighs. Continuous observations conducted over several hours on the same unit showed that this resident, along with three others who were either dependent or required maximum assistance for toileting, were not checked by staff for incontinence care during the observation period. Another resident with severe cognitive impairment and dependent on staff for toileting was left waiting in the hallway, during which a CNA walked past and remarked that she was not rushing before later providing care. When care was finally given, the resident’s pants were dry but the brief was heavily saturated with urine, and a linear indentation was noted on the proximal left leg, which the CNA attributed to sitting in the wheelchair. A third resident, requiring maximum assistance for toileting and not assisting with care, was found with a saturated brief when transferred to bed with a mechanical lift and two staff. A fourth resident, dependent on staff for toileting, was found with a small puddle of urine and a deep indentation on the chair cushion; the sling and clothing were saturated and dripping urine during transfer to bed. The DON stated that staff should be checking and changing residents every two hours and as needed.
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