Failure to Provide Timely Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate assistance with activities of daily living (ADLs), specifically incontinent care, for two residents who were dependent on staff for these needs. One resident, a female with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and hypertension, was observed to have a saturated incontinent brief that had not been changed for several hours. The certified nursing assistant (CNA) responsible admitted to not checking the resident's brief during her second round due to a high workload and acknowledged that she was trained to provide care every two hours. Both the Director of Nursing (DON) and the Unit Manager confirmed that staff are expected to check and change residents every two hours, and that failure to do so could result in skin breakdown. Another resident, a female with diagnoses including ovarian cancer, diabetes, and cystitis, and who was also dependent on staff for ADLs, was found with a soiled brief containing semi-dry feces and a stained draw sheet. The CNA assigned to her had not changed her for an extended period, stating she was working in another hall and had not yet reached the resident. The CNA and the licensed vocational nurse (LVN) both acknowledged that the resident's care was delayed and that such delays could lead to skin issues. The Assistant Director of Nursing (ADON) reiterated that staff are expected to round and provide care every two hours. Record reviews confirmed that both residents had care plans indicating the need for one or two staff to assist with toileting and ADLs, and that staff had been in-serviced on the requirement for two-hour rounding and care. However, observations and staff interviews revealed that these protocols were not consistently followed, resulting in residents being left in soiled briefs for extended periods. The facility's ADL policy was requested but not provided during the survey.