Failure to Ensure and Document Incontinence Care for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the provision and documentation of ADL care when a dependent resident did not have documented incontinence care on multiple shifts. The resident, who had Charcot-Marie-Tooth disease and was care planned as needing assistance with ADLs, including one-staff assist for bathing and a preference for bed baths, was assessed on the Quarterly MDS as cognitively intact and dependent on staff for toileting hygiene. During an interview, the resident reported not receiving routine incontinence care and being left in a wet brief for long periods of time. Review of CNA bladder elimination task documentation showed no recorded incontinence care on specified day, evening, and night shifts, despite the DON’s stated expectation that staff document incontinence care at least once per shift, three times daily, as required by 410 IAC 16.2-3.1-38(a)(3). The missing documentation dates included several day shifts, evening shifts, and night shifts over a span of weeks, indicating that incontinence care was either not provided or not recorded for this dependent resident on those occasions. The deficiency centers on the facility’s failure to ensure that ADL and incontinence care were consistently provided and documented for a resident who relied entirely on staff for toileting hygiene.
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