Failure to Provide Timely Incontinence Care Due to Staffing Assignment Delays
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including toileting and personal hygiene, did not receive timely incontinence care. The resident, who had diagnoses including conversion disorder, anarthria, and aphonia, was observed in bed with wet bedding, clothing, and sheets. The resident communicated to the surveyor that they had been wet for a long time and had not been changed. The care plan for this resident required staff to check for incontinence every two hours and as needed, and to provide peri-care after episodes. Staff interviews revealed that the assigned CNA had not changed the resident that morning, citing confusion over assignments at the start of the shift due to delays in finalizing the CNA staffing assignment. The Director of Staff Development confirmed that the assignment was not completed until after the shift began, which delayed care. The Director of Nursing stated that the staffing assignment should be ready before the shift so CNAs can provide immediate care. Facility policy required appropriate support and assistance with hygiene and toileting for residents unable to perform ADLs independently.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On March 27, 2025, Resident #1 was promptly provided with Activities of Daily Living (ADL) care by a facility CNA as soon as the deficient practice was identified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents had the potential to be affected by this deficient practice. On March 28th, 2025, Department supervisors conducted room rounds to follow up with residents to ensure there were no other concerns pertaining to ADL care. No additional findings were identified as a result. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From March 27 to March 28, 2025, licensed nurses and CNAs participated in an in-service training conducted by the Administrator/designee. The training focused on the importance of providing timely ADL care, with an emphasis on promptly responding to call lights to ensure residents' needs are consistently and adequately met. The Director of Staff Development (DSD)/Designee will conduct random daily rounds to ensure timely ADL care is being provided and that residents' needs are being consistently met. Any negative findings will be reported to the Director of Nursing (DON) for further review and appropriate follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will provide any negative findings to QAPI committee monthly x 3 months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: April 1st, 2025