Failure to Provide Adequate Incontinence Supplies and Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and provide equal access to incontinence care supplies, as evidenced by multiple resident and staff interviews, observations, and grievance documentation. Several residents reported that they did not have access to incontinence briefs for several days due to the facility running out of supplies. Residents described being told by staff to use towels as a substitute for briefs, and some residents delayed having their briefs changed or were given incorrectly sized briefs. One resident reported that a pull-up garment provided as an alternative leaked, resulting in wet bedding that required changing by staff. Staff interviews corroborated the residents' accounts, with several staff members stating that the facility ran out of briefs at the end of May and beginning of June. Staff described limited availability of pull-up garments, which were not suitable for all residents, and reported taking briefs from some residents' rooms to use for others. Staff also stated that they were instructed by management to use towels as a substitute for briefs and that supply orders were restricted due to budget concerns. Grievance forms further documented resident concerns about running out of supplies and being told by staff that briefs were unavailable. Facility leadership, including the DON and NHA, denied instructing staff to use towels or restricting supply orders, and stated that the facility did not run out of briefs. However, the consistent reports from residents and staff, as well as direct observations of supply shortages and the use of incorrect brief sizes, indicate that the facility did not ensure adequate and appropriate incontinence care supplies were available to all residents, compromising their dignity and individualized care.