Failure to Provide Timely Incontinence and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including incontinence care and oral hygiene, for five residents who required such support. Observations revealed that one resident, who had multiple medical diagnoses including stroke, aphasia, and dysphagia, was found with significant oral debris and reported not receiving oral care or bed baths. This resident was dependent on staff for personal hygiene and grooming, as documented in the care plan and minimum data set, but did not receive the required assistance. Another resident with a urostomy and hemiplegia reported a leaking urostomy pouch that was not changed in a timely manner, despite staff being aware of the issue. The certified nurse assistant stated she was not permitted to change the pouch and only placed a towel to catch the urine, while the LPN delayed changing the pouch due to lack of supplies and workload. The resident's care plan and physician orders required regular urostomy care and monitoring, which was not provided as ordered. Additional residents were observed with poor oral hygiene, including thick debris on teeth and gums, and one was found with a heavily soiled brief and bed linen due to incontinence. Staff interviews confirmed that oral care and incontinence care were not consistently provided, with one resident stating oral care was only given two to three times per week and supplies were not always made available. The Director of Nursing acknowledged that ADL care, including oral and incontinence care, should be provided regularly, but the administrator stated there was no specific policy in place for these services.