Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
The facility failed to provide timely incontinence care and adequate assistance with activities of daily living (ADLs), including showering and bathing, for six residents who required such support. Multiple residents with severe cognitive and physical impairments, including diagnoses such as neurocognitive disorder, dementia, hemiplegia, and muscle weakness, were documented as being dependent on staff for toileting hygiene and bathing. Care plans for these residents specified the need for regular incontinence checks, assistance with toileting, and scheduled showers or bed baths, yet these interventions were not consistently implemented. Observations, interviews, and record reviews revealed that residents were left in soiled clothing and bedding for extended periods due to insufficient staffing. Family members and staff reported that there were often not enough CNAs on duty to meet residents' needs, resulting in delays in providing incontinence care and missed opportunities for toileting. In several instances, residents were not offered or provided showers or bed baths for periods exceeding the facility's stated minimum frequency, and there was a lack of documentation to indicate that showers were refused or even offered. Staff interviews confirmed that short staffing was a persistent issue, making it difficult to complete scheduled care tasks, including two-hour bed checks and regular bathing. Documentation gaps were also identified, with missing or incomplete records for showers and refusals, and no facility policy in place for incontinence care or showering. Residents and their caregivers reported missed showers, prolonged periods without bathing, and inadequate assistance with toileting, all of which were corroborated by staff statements and review of care records. The facility's leadership was unable to explain the lapses in care or documentation, and acknowledged that the frequency of care provided did not meet the expected standards outlined in residents' care plans.