Failure to Provide Proper Size Incontinence Products
Penalty
Summary
A male resident with diagnoses including heart failure, obesity, and multiple myeloma, and with moderate cognitive impairment (BIMS 10/15), experienced repeated instances where the facility failed to provide the correct size incontinence products (3XL diapers) as needed. The resident reported that on weekends and night shifts, the proper size diapers were unavailable, resulting in staff using smaller, uncomfortable sizes. The resident's wife had to purchase the correct size diapers on several occasions due to the facility's lack of supply. This issue was corroborated by both the resident and his family member, who confirmed that the facility ran out of the required size multiple times. Multiple CNAs confirmed that they had to use smaller size diapers for the resident when the correct size was not available, and were unaware of additional supplies in the basement. Documentation from a resident concern form indicated that the resident was told the correct size was not available, and staff did not escalate the issue to supervisors or access the basement storage for additional supplies. The Director of Nursing later acknowledged that staff failed to follow the protocol of notifying security to access the basement storage for the needed supplies, resulting in the deficiency.