Failure to Provide Appropriately Sized Incontinence Briefs
Penalty
Summary
A resident with a history of bilateral primary osteoarthritis of the knee, morbid obesity, chronic knee pain, and muscle weakness was not provided with appropriately sized incontinence briefs. The resident, who was cognitively intact and frequently incontinent of bladder and always incontinent of bowel, reported that the briefs supplied by the facility were too small, causing discomfort and leaving her unable to fasten them properly. She repeatedly informed CNAs of her need for a larger size, but was told that larger briefs were not available. Observations confirmed that only 2 XL briefs were present in the resident's room and in the supply rooms on the second and third floors, while the resident required a 3 XL bariatric brief. Multiple staff interviews corroborated the resident's account, with CNAs and the interim DON acknowledging that the 2 XL briefs were not the correct size and that the appropriate 3 XL size was not stocked in the relevant supply rooms. The maintenance/housekeeping assistant confirmed that supply rooms are restocked daily and that specific sizes can be provided upon request, but no 3 XL briefs were available at the time. The facility's incontinence management policy requires care and services to prevent skin breakdown and maintain resident dignity, but the failure to provide the correct size brief did not meet these standards.