Failure to Provide Timely Incontinence Care per ADL Policy
Penalty
Summary
The facility failed to follow its Activities of Daily Living (ADLs) policy and procedure for three residents who were observed to be left soiled and wet. On April 30, 2025, observations and interviews revealed that one resident with diagnoses including encephalopathy, respiratory failure, tracheostomy status, and hypertension was found with a completely drenched brief, wet linen, and wet gown. The LVN present confirmed the resident's condition and stated that the CNA responsible was at lunch, with the last change occurring around 8 AM after a bowel movement. The CNA interviewed was unsure when the resident was last changed and acknowledged the resident was left wet for too long. The DON confirmed the resident's soiled condition and noted another resident was also found in a similar state. A second resident, with metabolic encephalopathy, chronic respiratory failure, type 2 diabetes, hypertension, and cerebral infarction, was also observed with a drenched brief and wet gown. The LVN confirmed this observation. A third resident, with cerebral infarction, acute respiratory failure, and type 2 diabetes, was found with a moderately wet brief. The CNA responsible stated that the residents were changed earlier in the morning and checked again before lunch, but both were heavy wetters and required frequent changes. The DON acknowledged that residents should be kept dry and repositioned, and that there was sufficient staff to provide care. The facility's ADL policy requires residents to receive necessary services to maintain hygiene, which was not followed in these instances.