Failure to Provide Timely Incontinent Care and Maintain Resident Hygiene
Penalty
Summary
A deficiency was identified when a resident who was fully dependent on staff for all activities of daily living (ADLs) was not provided timely and adequate incontinent care. The resident, who had multiple diagnoses including sepsis, pneumonia, a pressure ulcer, dysphagia, stroke, and was dependent on a feeding tube, was observed on the morning of 06/18/25 to be lying in bed with a soiled brief and bedding. The bedding had a brown ring and a strong ammonia odor, and the resident reported not having received incontinent care since the previous night, describing discomfort and itchiness. Staff interviews confirmed that the resident was changed at 6:00 AM, but by 9:12 AM, the resident was already found to be wet and soiled, indicating a lack of timely care. Further observations showed that the resident remained wet later in the morning, though without the brown ring or strong odor. The care plan for the resident specified that she was to be checked frequently for wetness and soiling and changed as needed, with the goal of maintaining cleanliness, dryness, and dignity. Staff interviews revealed that while CNAs were primarily responsible for providing ADL care, nurses were expected to monitor and assist as needed. However, the nurse on duty admitted to not checking if the resident was wet during her morning rounds, despite administering medications and checking blood sugar. Family interviews corroborated the findings, with reports of repeated incidents where the resident was found soiled, including during a previous hospitalization for pneumonia and a staph infection. The facility's policy required essential ADL services to maintain hygiene but did not specify the frequency of incontinent care. The Director of Nursing and the Administrator both stated that the expectation was for ADL and incontinent care to be provided every two hours or as needed, and acknowledged that the observed condition indicated a failure to meet these standards.