Inadequate Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as Resident #71, who was dependent on staff for assistance. During an observation, the surveyor found the resident seated in a wheelchair in the bathroom with two saturated incontinence briefs, which is against the facility's policy. The Hospitality Aide present was not assigned to provide direct care and had to summon the Certified Nursing Assistant (CNA) responsible for the resident. Upon arrival, the CNA confirmed the inappropriate use of double diapers and admitted to not having provided care to the resident that morning due to having 12 residents on her assignment. Resident #71 was admitted with chronic kidney disease, a fracture of the right femur, and hypertension, and had a severe cognitive impairment with a BIMS score of 7 out of 15. The resident required supervision with toileting and was frequently incontinent of urine. However, the resident's care plan did not address incontinence care, which was a requirement according to the facility's policy. The Director of Nursing acknowledged the oversight and confirmed that the care plan for incontinence care was not initiated until after the surveyor's inquiry.
Plan Of Correction
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that NJ Ex Order 26.4b1 was provided to a NJ Ex Order 26.4b1 resident for 1 of 4 residents reviewed for J Exec Order 26.461 care (Resident #71) on 1 of 2 nursing units, X-floor unit. 1. Corrective Actions Accomplished for residents found to have been affected by the deficient practice: "Resident #71 was assisted with NJ Ex Order 26.4(b)(1) NJ Ex Ord care immediately. was assessed, no changes in NJ Ex Order 26.4(b)(1) noted. "Education was provided by the Director of Nursing to U.S. FOIA (b) (6) regarding timely NU Ex Order 26.4(b)(1) care. "Plan of care updated for all residents who prefer to use. 2. Identification of residents who have the potential to be affected by the same deficient practice: "All incontinent and dependent residents have the potential to be affected by the deficient practice. 3. Systemic changes to ensure that the deficient practice does not recur: "Education provided by Director of Nursing to all nursing staff regarding timely incontinent care as per residents needs. "Residents requesting for two briefs will be evaluated quarterly and annually and preference will be included in the plan of care. "Incontinence rounds added/included in the unit managers daily rounding to ensure incontinence care is provided as per the residents needs. 4. Monitoring of corrective actions: "The Director of Nursing or designee will audit 5 incontinent residents weekly for month and then monthly for 6 months to ensure incontinent care is provided in a timely manner. "The Director of Nursing will audit all incontinent residents for preference of two briefs weekly for 1 months and then monthly for 6 months to ensure residents preference is reflected in the plan of care. "Results of the audit will be presented and reviewed during the quarterly Quality Assurance Performance Improvement (QAPI) meeting for 6 months, and additional corrective action will be implemented if deficiencies are identified.