Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting hygiene to dependent residents, as identified through observation, interview, and record review. Four residents with documented severe or moderate cognitive impairment and dependence on toileting hygiene were found with urine-soaked briefs and wet linens late in the morning. One male resident was observed in bed pointing to his soaked incontinent brief at 9:40 AM; a CNA who had started work at 7:00 AM acknowledged she had not yet changed him. His care plan included cleaning the peri-area with each incontinent episode. Another male resident was observed at 10:10 AM lying on a low bed wearing two incontinent briefs with wet mattress linens; the inner brief was urine-soaked with brownish discoloration. The CNA caring for him stated that she put two diapers on him because he urinated a lot and planned to change him to one diaper, despite his care plan directing staff to assist him by toileting frequently. A female resident with moderate cognitive impairment and dependence on toileting hygiene was observed at 10:15 AM in bed with a brownish discolored, urine-soaked incontinent brief. The CNA reported that this resident had last been changed around 7:00 AM by the night CNA and that she was going to change her at that time, although the care plan called for frequent toileting assistance. Another female resident with severely impaired cognition and dependent on toileting hygiene was observed at 10:20 AM with a urine-soaked brief showing brownish discoloration through to the outside of the brief and mild wet padding. A hospice CNA stated she visits this resident twice per week and was going to change her then. This resident’s care plan required incontinence care after every diaper change. The DON stated that it was not acceptable to leave residents in urine-soaked, brownish-colored briefs and referenced the issue of staff putting two diapers on residents and the need to check residents frequently.
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