Failure to Provide and Document Required Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary care and assistance, specifically in the area of incontinence care. Two residents with significant physical and cognitive impairments, including diagnoses such as Parkinson's disease, dementia, hemiplegia, and hemiparesis, were identified as being dependent on staff for toileting and incontinence care. Both residents had care plans in place that required staff to check and provide toileting care every two to four hours as tolerated. Record reviews revealed multiple instances where Certified Nurse Assistant (CNA) documentation for incontinence care was not signed, indicating that care may not have been provided as required. For one resident, there were five unsigned instances in June and seven in July. For the second resident, there were four unsigned instances in July and fourteen in August. These lapses occurred across various shifts, including day, evening, and night shifts, and were documented in the facility's electronic medical record system. Interviews with nursing leadership confirmed that CNA documentation is expected to be reviewed daily by supervisors and that missing documentation is followed up with staff. However, it was acknowledged that issues such as short staffing and assignment splitting sometimes contributed to incomplete documentation. Despite reminders and monitoring at multiple levels, including from the DON and corporate oversight, the problem of incomplete documentation persisted, and at the time of the survey, there was no consistent disciplinary action for failure to complete documentation.