Failure to Provide Appropriate Incontinent Care and Improper Use of Double Briefing
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate incontinent care for two residents who were always incontinent of bladder and frequently or always incontinent of bowel. Both residents were observed on separate occasions to be wearing two incontinent briefs (double briefed) at the same time, which is not in accordance with their care plans or facility policy. In both cases, the briefs were saturated with yellow liquid, and there was an odor of ammonia present in the residents' rooms. The residents reported not being changed for extended periods and expressed discomfort due to being wet. Resident #1 had a history of Parkinson's Disease, dementia, and functional quadriplegia, requiring extensive assistance with activities of daily living and was always incontinent of bladder. Resident #2 had dementia, morbid obesity, and muscle weakness, also requiring total or substantial assistance and was always incontinent of bowel and bladder. Both residents' care plans specified frequent checks and incontinent care, but observations and interviews revealed lapses in timely care and the inappropriate use of double briefs. Staff interviews indicated that double briefing was not an accepted practice and was not supposed to occur, yet both residents were found in this condition. The facility's policy and staff expectations required rounding and incontinent care at least every two hours, but these were not consistently followed, as evidenced by the residents' reports and the surveyors' observations.