Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to dependent residents, as observed by surveyors on the 2nd-floor unit. Four residents were found with saturated or soiled incontinence briefs, indicating a lack of regular care. Resident #66, with severe cognitive impairment, was found with a saturated pull-up and no care plan addressing incontinence. Resident #44, who was alert and oriented, reported not having a diaper change since the previous night, despite being dependent on staff for ADL care. Resident #49, with severe cognitive impairment, was found with a soiled brief containing urine and feces. Resident #29, also with severe cognitive impairment, was found with a saturated brief, and CNA #2 acknowledged that incontinence rounds should occur every two hours. The facility's policy on Activities of Daily Living (ADLs) requires that care plans address ADL needs and goals, including incontinence care. However, the observations revealed that the facility did not adhere to this policy, as evidenced by the lack of timely incontinence care for the residents. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that incontinence rounds should be conducted every two hours, but this was not consistently done, leading to the deficiencies observed by the surveyors.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #66, #44, #49, and #29 are having their [R] Ex Order 26.4b1 provided as per their plan of care. 2. Other Areas Affected: All residents who are incontinent have the potential to be affected by this practice. 3. Systemic Changes to Prevent Future Occurrences: DON/Designee has re-educated the nursing staff on incontinence care and documentation requirements. This information is included in the staff and agency Orientation program as well. An initial audit of incontinent residents has been completed by DON/Designee for care plan completion and compliance with identified toileting program. 4. Monitoring of Corrective Action: DON/Designee will conduct weekly observation audits x 4 then monthly x 2 of 5 incontinent residents on various shifts to verify incontinence care has been provided as per their plan of care. Results of the audits to be reviewed monthly at the facility's monthly Quality Assurance Improvement Meetings.