Failure to Provide Timely Incontinence Care
Summary
The facility failed to provide timely incontinence care for a resident, identified as R705, who was observed multiple times throughout the day with a soaked incontinence pad and wet bedding. Despite the presence of clean linens and briefs at the foot of the bed, the resident remained unchanged from the morning until the afternoon. The resident, who has Alzheimer's Disease and Bilateral Lower Extremity Contracture, was unable to recall when they were last changed and could not clearly express their feelings about being wet for an extended period. The Certified Nurse Assistant (CNA) responsible for R705's care confirmed that the resident was only changed once in the morning, around 7-7:30 AM, and not again until 2 PM. The Director of Nursing (DON) acknowledged that this was not acceptable, as the facility's policy requires checks and changes approximately every two hours and as needed. The facility's policy on Activities of Daily Living emphasizes the necessity of providing services to maintain good nutrition, grooming, and personal hygiene for residents unable to carry out these activities themselves.
Penalty
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Staff failed to consistently provide and/or document required ADL care, including incontinence care, turning/positioning, and bathing, for several dependent residents with bowel and bladder incontinence and significant cognitive impairment. One resident’s representative reported finding the resident in a wet brief on multiple weekend visits, while ADL records over several months showed numerous blank entries for incontinence care across all shifts despite care plans requiring continence care and facility policy mandating daily personal care and linen changes when soiled. Another resident, dependent for bathing, received only two showers over a two‑week period, contrary to policy requiring at least twice‑weekly showers, even though a CNA stated showers were given at least twice weekly and documented. Additional residents with incontinence and immobility had missing documentation of toileting hygiene and turning/positioning on specific dates and shifts, despite care plans directing staff to observe for moisture and provide care as indicated and CNAs describing a two‑hour rounding and documentation process in the electronic record.
Staff failed to provide and coordinate required bathing and hygiene assistance for four dependent residents. One cognitively intact resident with a history of falls reported only receiving basin baths and having to request showers, despite a care plan and ADL schedule for twice-weekly showers, and the ADON acknowledged showers were not documented. Another resident with a femur fracture stated he received his first thorough shower only on the survey day, although he was scheduled for twice-weekly showers and his room board lacked shower-day postings. A cognitively impaired resident dependent for self-care was repeatedly observed with oily hair, dry rough skin, and later an offensive odor, while records only showed two refusals of showers/tub baths and no alternative bathing. A fourth cognitively intact resident requiring substantial assistance for bathing reported she had not taken showers or tub baths because she believed hospital instructions about dressings prohibited immersion, and she stated no one at the facility had educated her that bandages could be removed and reapplied for bathing, despite documentation indicating she was receiving scheduled showers or tub baths.
Staff failed to consistently provide and document ADL and incontinence care for multiple dependent residents. One resident with an indwelling catheter was given a bed bath without any covering, with soap left unrinsed and the same washcloth used for both body washing and post-bowel incontinence care. A cognitively intact resident who required assistance with personal hygiene had visible chin hair despite expressing a desire for facial hair removal, which staff acknowledged should be part of routine ADL care. Another dependent resident with severe cognitive impairment and urinary incontinence received fewer showers than scheduled, and her family reported having to wash her hair at bedside due to lack of staff hair washing. Additional residents with significant ADL deficits and severe cognitive or physical impairments had multiple days and shifts with blank ADL documentation for hygiene and bowel/bladder continence, and staff interviews confirmed that care is evidenced by documentation in the electronic ADL system.
Two cognitively intact, dependent residents did not receive necessary ADL and incontinence care. One resident with a history of CVA, COPD, and GI bleed, care-planned for mechanical lift transfers and two-person toileting assistance, reported only receiving bed baths on night shift, being denied use of a shower chair despite requesting showers to protect her hair, and experiencing long delays in toileting and incontinence care from early morning until after lunch, even after activating the call light. Staff required use of a Hoyer lift, which the resident feared, and a CNA confirmed that incontinence care was routinely delayed and that the resident was not toileted because she used a Hoyer. Another resident with chronic pain, insomnia, COPD, obesity, and documented ADL self-care deficits reported remaining wet for prolonged periods, including from late night until morning, and stated that it often took 30–60 minutes or more for staff to respond, sometimes requiring her to call her son to contact the nurse’s station.
Staff failed to provide timely incontinence care and repositioning for a dependent resident with multiple medical conditions, resulting in the resident remaining in bed for over five hours without necessary ADL assistance. Upon eventual care, the resident was found with a wet brief, a small bowel movement, and a new pink area on the sacrum. Facility leadership confirmed this lapse exceeded expected care intervals.
A resident with complex medical needs, including nephrostomy tubes and severe heart failure, did not receive adequate bathing or ADL care during a 43-day stay. Despite staff indicating that showers or tub baths are typically provided twice weekly and daily bed baths as needed, the resident received only three bed baths and had two documented refusals, with no other hygiene care documented. Other residents were found to have received appropriate hygiene care.
Failure to Provide and Document Required Incontinence Care and Bathing for Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, specifically incontinence care and bathing, to multiple dependent residents as documented in clinical records, interviews, and facility documents. One resident with severe cognitive impairment, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, had extensive gaps in ADL documentation over several months. ADL records from January through March showed multiple dates and shifts where incontinence care entries were left blank, despite a care plan stating the resident’s bowel and bladder continence needs were to be met and a facility policy requiring daily personal care and clean clothing and linens each time they were soiled. The resident’s representative reported visiting on weekends and finding the resident’s brief appearing wet for hours. CNAs interviewed stated that incontinence care was provided every two hours and documented as evidence of care, but the records did not reflect consistent documentation. Another resident, moderately cognitively impaired and dependent for showering and bathing, did not receive showers at the frequency required by facility policy and the resident’s care plan. Clinical documentation over a two‑week period showed that the resident received only two showers, even though the policy required tub/shower baths not less than twice weekly and the care plan specified assistance with bathing and hygiene as required. The resident’s authorized representative expressed concern that the resident was not being showered regularly. A CNA reported that showers were given at least twice a week and documented in the electronic system, and that refusals were verified by the nurse, but the documentation reviewed did not show showers being provided at the required frequency. Additional residents with bowel and bladder incontinence and dependence on staff for toileting, hygiene, and positioning also had missing documentation of incontinence care and turning/positioning on specific dates and shifts. One resident, frequently incontinent and dependent on staff for toileting, had no documented toileting hygiene on two night shifts in June, despite a care plan directing staff to observe for moisture and provide care as indicated. Two other residents, both severely cognitively impaired, dependent for locomotion, transfer, dressing, toileting, and hygiene, and care‑planned for bladder and bowel incontinence and risk for pressure ulcer development, had ADL records with missing evidence of incontinence care and turning/positioning on multiple day and night shifts across several months. CNA interviews described a process of rounding at the beginning of the shift and then every two hours, with all care documented in the electronic record and the understanding that if it is not documented there is no evidence it was done, yet the reviewed records contained numerous blank entries for required care.
Failure to Provide and Coordinate Scheduled Bathing and Hygiene Assistance
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically bathing and hair washing, to multiple dependent residents. One resident with a history of repeated falls and unsteadiness on feet was cognitively intact and had a care plan emphasizing her preference and goal to increase functional ability with bathing, including choosing between a tub bath, shower, bed bath, or sponge bath. She reported that staff were relying on her to ask for showers, that she believed she had designated shower days, and that she had instead been taking basin baths and using washcloths to run through her hair. ADL records showed scheduled showers twice weekly, but documentation reflected self-bathing on one date and "NA" on another, and the ADON later acknowledged that showers were not documented for this resident and that her preference for daytime showers had not been aligned with the existing schedule. Another resident admitted with a right intertrochanteric femur fracture, and diagnoses including repeated falls and unsteadiness on feet, reported that he received his first shower on the morning of the survey interview, stating that it was the first thorough washing since admission. He stated that staff had not bathed him in the shower room or in bed prior to that day, although he had been able to perform limited self-care such as shaving, wiping himself with a washcloth, and brushing his teeth. Staff interviews indicated that showers or refusals were to be documented in the electronic record, that there was a set shower schedule, and that shower days should be posted on room boards and in CNA computers. The resident’s room board did not list shower days, although an LPN confirmed that the resident was scheduled for showers twice weekly on the day shift. ADL documentation showed the first recorded shower on a date consistent with the resident’s report and an earlier scheduled date marked as "NA." A third resident with Alzheimer’s dementia and paroxysmal atrial fibrillation, who was severely cognitively impaired and dependent or requiring substantial assistance for most self-care tasks including showering/bathing, was observed on two separate days with oily, flat hair, dry rough skin on the face, and later with an offensive odor. Her care plan included a goal to increase functional ability with bathing and interventions allowing her to choose the type of bath while requiring substantial/maximal assistance. A family member reported that her hair had not been washed for weeks and that he planned to ensure her hair was washed before transfer to another facility. Bathing records showed refusals of showers/tub baths on two dates, with no documentation of alternative bathing or hair washing. A fourth resident, cognitively intact but requiring substantial/maximal assistance with showering/bathing and several other ADLs, had a care plan goal to increase functional ability with bathing and interventions emphasizing her choice of bathing method. She was observed with multiple scabs on her arms and legs, dry and scaly skin on her arms, legs, and face, and hair that had been washed and set at the beauty shop that day. She stated she was not taking showers or tub baths because hospital staff had told her she could not immerse in water due to dressings, and she reported that no one at the facility had informed her that bandages could be removed and reapplied to allow bathing. CNA interview indicated that every resident received showers or tub baths as scheduled, and documentation stated that this resident was receiving showers or tub baths according to her schedule, but the resident’s own account and the DON’s subsequent interview confirmed that she had not been receiving showers or tub baths at the facility due to her understanding of the hospital’s instructions and lack of education from facility staff.
Failure to Provide and Document Adequate ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide appropriate activities of daily living (ADL) and incontinence care for multiple dependent residents, as evidenced by observations, interviews, and record reviews. One cognitively intact resident with an indwelling Foley catheter and dependence for toileting hygiene, bathing, and footwear was observed receiving a bed bath and incontinence care that did not follow basic hygiene practices. The CNA removed dirty linens without using a bed/bath blanket or towel, leaving the resident exposed throughout the bath, used only one basin of water, washed the resident’s upper body and lower extremities, and then dried the resident without rinsing off soap. The CNA then removed the resident’s brief and used the same soapy washcloth that had been used for the body bath to clean the perineal area after a bowel movement before discarding it, and later stated she had been taught to provide bed baths in this manner. Another cognitively intact resident with a need for assistance with personal care and an overactive bladder, who required setup or cleanup assistance for bathing, oral hygiene, and personal hygiene, was observed with medium-length chin hair. During interview, this resident stated she wanted both her hair and chin/facial hair trimmed. Staff interviews confirmed that removal of facial or chin hair is considered part of ADL care and should be provided during scheduled showers twice weekly, but the resident’s facial hair had not been addressed. A different dependent resident with severe cognitive impairment and urinary incontinence, who was coded as dependent for eating, oral hygiene, toileting, bathing, and personal hygiene, reported through her daughter that she wanted more showers and hair washing. The daughter produced a modified bath basin she used at bedside to wash her mother’s hair because, according to her, staff would not wash it. Review of ADL documentation showed the resident was scheduled for baths/showers twice weekly, but records for December and January reflected missed or reduced bathing, including days with no documented baths/showers and a pattern of only one shower per week over a two‑month period. Additional dependent residents with significant ADL self-care deficits had missing documentation for hygiene and incontinence care on multiple dates and shifts. One resident with CVA, diabetes, epilepsy, hemiplegia, impaired balance, and limited mobility, who was dependent for mobility, transfers, bathing, dressing, and toileting, had gaps in ADL records for hygiene and bowel/bladder continence across several days and shifts in December and January. Another resident with impaired mobility, maximal assist needs for bed mobility, transfers, and hygiene, and intact cognition had missing documentation for hygiene and bowel/bladder continence on multiple January shifts. A further resident with schizoaffective disorder, depression, severe cognitive impairment, and a need for one-person assistance with personal hygiene had extensive blanks on ADL tracking sheets for personal hygiene over numerous consecutive days in November and December, covering all shifts. CNAs and an RN stated that hygiene and incontinence care are documented in the electronic ADL system and that missing documentation means care was not done, but one CNA also stated she did not know what the blanks indicated, and no additional information was provided before survey exit to clarify or reconcile these omissions.
Failure to Provide Timely ADL and Incontinence Care to Two Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary ADL care, including bathing, toileting, and incontinence care, to two cognitively intact, dependent residents. One resident, with a history of stroke with right-sided weakness, GI bleed, and COPD, had a care plan identifying ADL self-care deficits and specifying use of a mechanical sit-to-stand lift with two staff for transfers, two-person assist for toileting, and individualized interventions for bathing, dressing, and clothing selection. Despite this, the resident reported that night-shift CNAs routinely provided only bed baths, dressed her, and transferred her to a wheelchair around 5:30 AM, and that she was not offered showers as desired. She stated she wanted showers using a shower chair to avoid getting her hair wet and undoing professional hair styling, but staff insisted on using a shower bed and documented her as refusing showers when she would not agree to the shower bed. The same resident reported significant delays and lack of toileting assistance throughout the day. She stated she was aware of her need to toilet but had to wait so long for assistance that she often urinated in her incontinence brief and had to strain to have bowel movements while waiting for staff. She reported not being offered toileting every 2–3 hours as she had been told was the expectation and not receiving incontinence care from approximately 5:30 AM until after lunch, at which time her brief was described as extremely saturated. She also stated that when she activated the call light, staff would respond, acknowledge her need, say they needed to get help, and then not return for hours, often not until after lunch. The resident expressed fear of the Hoyer lift and stated she was strong enough to use a sit-to-stand lift, but staff required Hoyer use for transfers. The Ombudsman confirmed frequent complaints from this resident about incontinence care, bathing, toileting, and repositioning, and a CNA reported that the resident was not toileted because she used a Hoyer lift and that incontinence care was routinely delayed until after lunch. A second resident, originally admitted with diagnoses including chronic pain and insomnia and assessed as cognitively intact with a BIMS score of 15, was coded on the MDS as dependent for showering/bathing, toileting hygiene, lower body dressing, and footwear, and as needing assistance with personal and oral hygiene. The person-centered care plan identified an ADL self-care performance deficit related to COPD and obesity, with interventions including encouraging the resident to use the call bell and discussing concerns about loss of independence and decline in function. This resident reported that for about one and a half weeks she had not been changed for hours and had to lie in her own wetness, stating it took 30 minutes to an hour before staff checked on her and that she sometimes called her son to contact the nurse’s station. In a follow-up interview, she reported remaining wet from late at night until after 7:00 AM the next morning. The facility leadership was unable to provide additional information to refute or clarify these concerns during the final interview.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically incontinence care and repositioning, to a resident who was completely dependent on staff for these needs. The resident, who had significant medical conditions including intracerebral hemorrhage, hemiplegia, aphasia, chronic respiratory failure, and was always incontinent, was observed in bed for at least five continuous hours without staff checking for incontinence or repositioning. During this period, only brief interactions occurred for medication administration and tube feeding, with no ADL care provided. When staff eventually entered the room to provide care, the resident was found with a wet brief containing a small bowel movement and a newly observed pink area on the sacral region, which had not been present two days prior. Interviews with staff and the DON confirmed that the facility's expectation was to check dependent residents for incontinence and repositioning at least every two to four hours, and the observed lapse exceeded this standard. The documentation reviewed did not specify required frequency for incontinence care, and no additional information was provided by facility leadership regarding the incident.
Failure to Provide Adequate Bathing and ADL Care to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate bathing and activities of daily living (ADL) care to a dependent resident with significant medical needs, including nephrostomy tubes, chronic heart failure, and an artificial heart valve. The resident was admitted with an order for oxygen and had a severely weakened heart muscle. Review of ADL records showed that the resident received only three bed baths during a 43-day stay, with only two documented refusals for bathing. No other baths or showers were provided during this period, despite the resident's condition requiring frequent hygiene care due to the presence of nephrostomy tubes, which are known to leak and necessitate regular cleaning. Interviews with staff indicated that the standard practice was to provide showers or tub baths twice weekly and daily bed baths as needed. However, this standard was not met for the resident in question. Other residents reviewed during the survey were found to have received adequate hygiene care, and no issues were reported by other residents or family members. The deficiency was communicated to the Director of Nursing and Assistant Director of Nursing, who did not provide additional information.
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