Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) and timely incontinence care for multiple residents. One resident with multiple sclerosis, epilepsy, and partial quadriplegia was dependent on staff for showering and bathing, as documented in her care plan. Despite repeated requests to staff across several shifts, she did not receive a shower for over a week after moving rooms, as she was not included on the shower schedule. Certified Nursing Assistants (CNAs) confirmed the resident was not on the schedule and were unsure of the process for adding her, resulting in her continued lack of access to showering. Three other residents, all with significant physical or cognitive impairments and documented incontinence, did not receive timely incontinence care. One resident, dependent on staff for all ADLs and non-verbal, was found in a wheelchair with clothing and a lift pad saturated with urine after being up since the start of the shift, with staff unable to state when incontinence care was last provided. Another resident with dementia and incontinence was also found in a wheelchair with a saturated brief and stale-smelling urine, with staff again unable to confirm when care was last given. Both CNAs acknowledged residents should be checked for incontinence at least every two hours. A further resident, who was cognitively intact but dependent for mobility and toileting due to obesity and muscle weakness, was observed lying in bed with bedding and clothing saturated with urine and a strong foul odor. She reported not being checked or changed since early morning, despite requesting assistance at breakfast. The assigned CNA confirmed this was the first time the resident was checked during her shift and that assistance was delayed due to staffing constraints. Facility policy required residents to be checked every two hours, including during sleep, but this was not followed for these residents.