Failure to Provide Adequate Incontinence Supplies
Penalty
Summary
The facility failed to provide necessary incontinence supplies for three dependent, incontinent residents, resulting in the use of incorrect or inadequate products. Documentation for these residents showed that their care plans required specific interventions, such as the use of disposable briefs in the correct size, regular checks every two hours, and proper perineal care after incontinence episodes. However, interviews with residents and staff revealed that the facility repeatedly ran out of appropriately sized incontinence briefs, cleansing wipes, washcloths, and bed pads. Staff reported substituting smaller or larger briefs, using pull-ups instead of briefs, and resorting to makeshift alternatives such as pillowcases and blankets when standard supplies were unavailable. Residents affected by these shortages included individuals with significant cognitive and physical impairments, such as muscle weakness, unsteadiness, neurocognitive disorders, and complete dependence on staff for toileting hygiene. One cognitively intact resident reported discomfort from being provided with briefs that were too small, while staff described frequent leaks and skin contact with urine or feces when using ill-fitting or less absorbent products. Staff also noted that the use of pull-ups in place of briefs was not effective for residents with total incontinence, as these products did not provide adequate coverage or absorbency, leading to soiled bedding and increased risk of skin issues. Multiple CNAs and nurses confirmed that supply shortages had been ongoing for several weeks to months, with some reporting that the facility was out of certain supplies an average of three days per week. Staff consistently reported these shortages to administration, who sometimes responded by instructing staff to use alternative products or by stating that supplies were on back order. Despite these reports, administration was either unaware of the extent of the shortages or minimized their significance, attributing staff concerns to reluctance to retrieve supplies from laundry or misunderstanding the nature of grievances. The lack of a facility policy regarding towels was also noted during the investigation.