Failure to Provide Adequate Incontinence Supplies and Reasonable Accommodation
Penalty
Summary
Lafayette Manor failed to provide reasonable accommodation of resident needs and preferences regarding incontinence care supplies for five of 25 residents reviewed. Observations and staff interviews revealed that the facility imposed a limit of eight incontinence diapers per resident per 24 hours, regardless of individual needs. Staff reported that if additional diapers were needed, they had to wait for a supervisor, and some residents received the wrong size of incontinence products. Additionally, there were reports of insufficient wipes, leading to the use of washcloths that were sometimes not clean, with concerns that these cloths may have been used on multiple residents for different purposes. Clinical record reviews indicated that one resident with a history of incontinence and a recently healed sacral pressure ulcer developed a urinary tract infection, while four other residents developed incontinence-associated dermatitis during their stay. The facility's supply practices and lack of appropriate incontinence care products contributed to these conditions. The Nursing Home Administrator confirmed the failure to provide reasonable accommodation for the affected residents.
Plan Of Correction
1. R1, 2, 3, 4, and 5 were assessed for incontinence and brief size. 2. Current residents will be assessed for incontinence episodes by the director of nursing / designee by 8/25/2025. 3. Current residents will be measured for appropriate size briefs by the director of nursing / designee by 8/25/2025. The Director of Nursing/Designee will complete an audit of current residents to ensure an adequate amount of incontinence supplies are available. 4. The Director of Nursing / designee will educate nursing staff and agency on inventory control, supplies, and storage location of incontinence supplies. 5. The Director of Nursing / designee will complete an audit to ensure sufficient incontinence supplies and appropriate brief size are stored in resident rooms weekly for 4 weeks and monthly for 2 months. 6. Findings of audits will be reviewed in QAPI.