Failure to Provide Timely Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide timely incontinence care and scheduled showers for multiple residents who were dependent on staff for activities of daily living (ADLs). One resident with severe cognitive impairment and total dependence for ADLs was found to have not received incontinence care for three and a half hours, despite care plans requiring assistance every two hours and as needed. During observation, staff did not use required personal protective equipment (PPE) while providing care, and soiled wipes were placed on the resident's bed instead of being disposed of properly. The resident was found to be soaked through their brief and incontinence pad, with a strong odor of urine present, and the fitted sheet was not changed after contamination. Several residents did not receive showers according to their scheduled frequency. One resident, dependent on staff for showers and other ADLs, received only six out of thirty scheduled showers. Another resident, also dependent on staff for personal care and showers, received only one shower in February, eight in March, and seven in April, despite being scheduled for three showers per week. Two additional residents received only two and four showers, respectively, out of seventeen scheduled sessions. Documentation confirmed these missed showers, and interviews with staff and residents corroborated that showers were often not completed as scheduled, with some residents and families voicing complaints. Facility policy required that residents be interviewed about their bathing preferences upon admission and that these preferences be reviewed quarterly. Staff were expected to assist with daily hygiene and showers per policy. However, interviews with CNAs, LPNs, and RNs revealed that showers were frequently missed due to time constraints, and staff only completed assigned showers if time allowed. The facility's leadership confirmed the discrepancies in shower provision and acknowledged the lack of documentation for missed showers.