Failure in Hand Hygiene and Catheter Care
Summary
The facility failed to adhere to proper hand hygiene protocols during catheter care for a resident, which could lead to potential contamination. Certified Nursing Assistants (CNAs) V33 and V34 did not wash their hands before donning gloves to provide catheter care for the resident. After completing the catheter care, they continued to handle the resident's incontinence brief, sheets, blankets, and call light with the same gloved hands, and subsequently exited the room without performing hand hygiene. Both CNAs confirmed their failure to perform hand hygiene before and after the catheter care. Additionally, the facility did not ensure that the resident's urinary catheter drainage bag was consistently covered with a dignity bag, as required by the facility's Catheter Care and Maintenance Policy. On multiple occasions, the drainage bag was observed hanging uncovered on the bed frame, visible from the hallway. This was only corrected on the third day of observation. The facility's Hand Washing Policy emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, requiring staff to wash hands before and after direct contact with residents and after removing gloves.
Penalty
Resources
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A resident with a femur fracture, history of falls, unsteadiness, and occasional incontinence, who was cognitively intact and required assistance with transfers and toileting, repeatedly requested a bedside urinal but was not provided one. Over several observations, surveyors found the urinal stored in a bag in the bathroom rather than at the bedside, while the resident stated he had not received the requested urinal. CNAs reported that they typically did not allow bedside urinals, citing infection control and a practice of keeping urinals in the bathroom and instructing residents to use the call light for assistance, whereas an LPN stated that residents who cannot transfer independently are allowed bedside urinals to help prevent falls. Leadership later acknowledged there was no policy on bedside urinals and that the resident could have one if able to use it.
A cognitively intact resident with right-sided weakness and ADL deficits reported that CNAs routinely provided a bed bath, dressed her, and transferred her early in the morning but did not offer toileting every 2–3 hours as expected. She stated that when she used the call light for toileting or incontinence care, staff would respond, say they needed another CNA due to Hoyer lift use, and then not return for hours, often not until after lunch, resulting in frequent incontinence and straining for bowel movements. An Ombudsman confirmed frequent complaints about incontinence care, bathing, toileting, and repositioning. A CNA acknowledged that incontinence care was typically not provided until after lunch and that the resident was not toileted because she used a Hoyer lift, and also reported never seeing a toileting-specific Hoyer pad. Facility leadership later asserted that special equipment and less-restrictive transfer interventions were available for the resident but could not produce documentation to support this.
Staff failed to provide incontinence care for a cognitively impaired, fully incontinent resident over a period exceeding seven hours, despite facility practice and staff interviews indicating that such care should be provided at least every two hours. The resident was moved between common areas but was not taken for incontinence checks or care during this time.
A resident with quadriplegia and an indwelling catheter did not receive or have documented required catheter care, including regular flushes and output monitoring, as ordered by the physician and outlined in the care plan. Review of records showed multiple missed entries for catheter care and monitoring over several months, and staff confirmed that undocumented care was not performed.
A resident with an indwelling catheter for urinary retention was observed with their catheter collection bag lying on the floor, despite care plan interventions and physician orders requiring the bag to be kept off the floor. This failure to maintain proper catheter care was identified during a survey and reported to facility administration.
A resident with recent spinal surgery and mild cognitive impairment did not receive timely toileting assistance upon request, resulting in incontinence episodes. The resident required partial to full assistance for transfers and relied on a Stedy lift, but staff were often unavailable or unable to locate the lift, leading to delays. The resident was encouraged to use incontinence briefs due to these issues, despite being aware of her toileting needs.
Failure to Provide Requested Bedside Urinal to Continent Resident
Penalty
Summary
Facility staff failed to provide a requested bedside urinal to a continent/occasionally incontinent resident who had a right intertrochanteric femur fracture, repeated falls, and unsteadiness on their feet. The resident’s admission MDS showed intact cognition (BIMS 15/15), partial/moderate assistance needs for toileting hygiene, and substantial/maximal assistance for bed-to-chair and toilet transfers, with occasional bladder incontinence. The resident’s care plan indicated partial/moderate assistance with toilet use and use of incontinent briefs, and that the resident was able to make self-care decisions daily. On multiple observations over several days, surveyors noted that the resident’s urinal was stored in a bag in the bathroom and not at the bedside, despite the resident’s repeated statements that he had requested, but not received, a bedside urinal. On one observation, when the resident directly asked a CNA for a bedside urinal, the CNA responded that he could not have one at the bedside and must use the call bell to request assistance with using the urinal in the bathroom. In interviews, one CNA stated that bedside urinals were not usually provided due to infection control and that residents were educated to use the call light for assistance, while another CNA stated that if a resident could walk, the urinal would be left in a bag in the bathroom. In contrast, an LPN reported that residents who cannot transfer independently are allowed to have bedside urinals and that staff use them to prevent falls and keep them close so residents do not get up impulsively. The ADON later stated there was no policy regarding bedside urinals and that the resident could have a bedside urinal if able to use it. Throughout the observation period, the resident consistently reported not being provided with the requested bedside urinal.
Failure to Provide Timely Toileting and Incontinence Care for Cognitively Intact Resident
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to assist Resident #79 in achieving and maintaining bowel and bladder control and dignity in toileting and incontinence care. Resident #79, who had a history of stroke with right-sided weakness, GI bleed, and COPD, was cognitively intact per a BIMS score of 15/15 and had a care plan identifying ADL self-care deficits with goals to improve function. The care plan interventions included use of a mechanical sit-to-stand lift with two staff for transfers and two-person assist for toileting, as well as support for bathing and dressing. Despite this, the resident reported that night-shift CNAs routinely provided a bed bath, dressed her, and transferred her to a wheelchair at 5:30 AM, and that she was not offered toileting every 2–3 hours as she had been told was the expectation by licensed nursing staff. Resident #79 stated she was aware of her need to toilet but had to wait extended periods for assistance because staff required use of a Hoyer lift, which needed two CNAs. She reported that when she used the call light, staff would respond, state they needed to get help, and then not return for hours, often not until after lunch, resulting in her frequently urinating in her brief and having to strain to have bowel movements while waiting. She further stated she did not receive any bowel or bladder care from 5:30 AM until after lunch, and that when incontinence care was finally provided, her brief was extremely saturated. The Ombudsman confirmed frequent complaints from the resident about incontinence care, bathing, toileting, and repositioning. CNA #4 acknowledged checking on the resident but not providing incontinence care until after lunch and stated the resident was not toileted because she used a Hoyer lift, and that she had never seen a special Hoyer pad for toileting or showers. During the final interview, facility leadership claimed such a special Hoyer pad and less-restrictive transfer interventions existed for the resident, but they were unable to provide any documentation or evidence of these interventions.
Failure to Provide Timely Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide timely incontinence care for one resident who was observed continuously from 10:07 a.m. to 5:30 p.m. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken to her room for incontinence checks or care. Staff interviews confirmed that the standard practice is to check incontinent residents at least every two hours, with some staff indicating even more frequent checks for residents unable to communicate their needs. However, the assigned CNA admitted that, despite walking by and checking in on the resident, she did not take the resident to her room for incontinence care at any time during her shift. The resident's most recent assessment indicated severe cognitive impairment, inability to communicate needs effectively, and total dependence on staff for toileting. Facility management and staff acknowledged that extended periods without incontinence care could lead to skin breakdown and emotional distress. A review of the facility's urinary elimination policy did not specify the required frequency for incontinence care, and no additional relevant documentation was provided prior to the survey exit.
Failure to Provide and Document Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide and document required treatment and services for a resident with an indwelling catheter. The resident, who was admitted with diagnoses including quadriplegia, spinal stenosis, and a history of TIA, was assessed as cognitively intact but fully dependent for activities of daily living. The resident's care plan and physician orders specified the need for regular catheter care every shift, daily catheter flushes, and monitoring of catheter output. However, review of the medication and treatment administration records over several months revealed multiple instances where these required treatments and monitoring were not documented as completed. Interviews with nursing staff confirmed that if catheter care was not documented, it was not performed. The facility's own urinary catheterization policy required licensed nurses to perform and document catheter care every shift. Despite these requirements, there was missing documentation for catheter output monitoring, catheter flushes, and catheter care on several shifts, indicating a failure to provide the ordered care and services for the resident's indwelling catheter.
Failure to Maintain Proper Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate care and services for an indwelling catheter for one resident. Specifically, the staff did not keep the resident's catheter collection bag off the floor, as observed during the survey. The collection bag was found lying flat on the floor next to the resident's bed, contrary to the care plan intervention that required the catheter to be kept off the floor. The resident had a diagnosis of urinary retention and was alert with some forgetfulness at the time of admission. The physician's order specified the use of a 16FR indwelling catheter with a 10cc balloon to bedside straight drainage for urinary retention. The comprehensive care plan, initiated upon admission, included an intervention to keep the catheter off the floor. Despite these documented requirements, the deficiency was observed and brought to the attention of administrative staff, with no additional information provided prior to the survey team's exit.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
Facility staff failed to provide timely toileting assistance upon request for one resident who was recently admitted following an acute care hospital stay. The resident had undergone an L2-L5 laminectomy and fusion and experienced left upper extremity edema due to a superficial vein thrombosis. Assessments indicated mild cognitive impairment and partial to moderate assistance required for mobility, with dependency for sit-to-stand and transfer activities. The resident was not attempted for toilet or shower transfers due to medical or safety concerns, and a note in the room indicated a need for two-person assistance with a Stedy lift for transfers. The resident reported frequent incidents where staff did not respond in time to her requests for toileting, resulting in accidents, including an episode of diarrhea that soiled her back. She stated that staff encouraged her to wear incontinence briefs due to these delays and that the inability to locate the required lift or lack of available staff contributed to the problem. The resident expressed concern about regaining independence in toileting before discharge, as she would not have assistance at home. Staff interviews confirmed that information about transfer needs was communicated via the whiteboard in the resident's room.
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