Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, leading to a deficiency in promoting the resident's quality of life. During a facility tour, the resident was observed calling for help for approximately 30 minutes without receiving assistance. The resident expressed a need for toileting and incontinence care, stating she had soiled herself and wanted to be clean. Despite her continuous calls for help, multiple staff members, including LPNs, CNAs, and other facility personnel, walked past her room without responding to her needs. The resident's care plan indicated she was incontinent of bladder and bowel and required assistance with toileting and personal hygiene. The care plan aimed to establish a resident-specific toileting program to support continence, reduce infection risk, and improve self-esteem. Additionally, the resident had a behavior problem of continuously calling out for help, with interventions to anticipate and meet her needs. However, during the observed period, staff failed to enter the resident's room to address her calls for help, despite the care plan's directives. Interviews with facility staff, including the DON, confirmed the resident's need for timely care, especially given her condition, which included a wound on her sacrum. The DON acknowledged that staff should have responded to the resident's calls for help, regardless of their position within the facility. The report highlights a lack of adherence to the resident's care plan and a failure to provide necessary incontinence care, resulting in a deficiency in the resident's quality of life.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any rights to contest any of these allegations or any allegation or action. F-675 Quality of Life Element #1. Resident #2 was provided with care on in response to her requests, and no adverse outcomes were noted. Care plans for Resident #2 were reviewed and deemed appropriate. Element #2. Director of Nursing (DON) and/or Designee conducted an interview audit to all current residents on to determine if their verbalizations/requests for care were responded to and addressed in a timely manner. No residents were identified. Element #3. Policy regarding Customer Service was reviewed by the Interdisciplinary Team (IDT) and deemed appropriate. Staff A (Licensed Practical Nurse/LPN), Staff B (Certified Nursing Assistant CNA), Maintenance Director, Activities Director, and Staff D (Licensed Practical Nurse/LPN) were individually in-serviced by Director Of Nursing (DON) regarding the expectation that staff respond to and address resident verbalizations/requests to ensure that they are addressed in a timely manner. Element #4. Director of Nursing (DON) and/or Designee will conduct random interview audits with interviewable residents three (3) times a week for four (4) weeks, then two (2) times weekly times eight (8) weeks and/or until substantial compliance is achieved to ensure that resident verbalizations/requests for care are responded to and addressed in a timely manner. Grievances will be completed on behalf of those residents who are verbalizing concerns. Completed audits will be brought to the daily stand-up meetings and reviewed by the Interdisciplinary Team (IDT). Results of the audits will be brought by the Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement Meetings for review and recommendation for three (3) months. Element #6: Facility's Allegation of Compliance Date is