Failure to Consistently Provide Appropriate Toileting Supplies
Penalty
Summary
The facility failed to consistently provide necessary toileting supplies, specifically briefs, for two residents with moderate cognitive impairment who required staff assistance for toileting hygiene. One resident reported that the facility had run out of their size of brief on three occasions since admission, resulting in the use of smaller briefs that were uncomfortable and did not adequately contain urine, leading to leakage. Another resident stated that staff sometimes used larger briefs when the correct size was unavailable, which did not always prevent wetness. Both residents were able to communicate their needs, and their experiences were corroborated by staff interviews. Staff, including a CNA and Central Supply personnel, confirmed that the facility occasionally ran out of briefs and would substitute with different sizes or obtain supplies from a sister facility, sometimes with delays of up to 12 hours. The administrator was unaware of the need for daily approval of supply orders and acknowledged that the facility should not have been running out of briefs. These actions and inactions resulted in residents not consistently receiving appropriate toileting supplies, as required.