Deficient Incontinence Care and Delayed Meal Delivery
Penalty
Summary
Surveyors identified deficiencies related to the provision of incontinence care and timely meal delivery for residents. On the observed unit, there was only one CNA present to distribute breakfast trays, resulting in meal trays being left unattended and not delivered to residents within the expected timeframe. The DON confirmed that meal trays should be delivered within 5 to 10 minutes of arrival to keep food warm, but observations showed that the last tray was not delivered until significantly later. Staff interviews revealed that the lack of a written policy and reliance on verbal communication contributed to inconsistent meal delivery practices. Incontinence care deficiencies were also observed for two residents. One resident, who was cognitively impaired and required extensive assistance with ADLs, was found to be wearing double incontinence briefs, a practice not documented in the care plan and not in line with facility expectations unless specifically requested and documented. The CNA responsible stated that the double briefs were applied at the resident's request, but the RN and LPNS were unaware of this and confirmed it was not standard practice. The resident's care plan did not reflect this preference, and the DON stated that such preferences should be documented, especially for residents who are cognitively intact. A second resident was also found with double incontinence briefs, with staff unable to confirm who applied them and the care plan not reflecting this intervention until after surveyor inquiry. The resident was moderately cognitively impaired and had a history of urinary incontinence. The DON stated that double briefs should only be used if requested by the resident and documented in the care plan, and that this practice increases the risk of skin impairment and urinary tract infection. Facility policies reviewed did not provide clear guidance on the use of double incontinence briefs or the process for meal tray distribution, contributing to the observed deficiencies.