Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for residents who were unable to carry out activities of daily living, specifically related to incontinence care. One resident with severe cognitive impairment and complete dependence on staff for all activities was not provided incontinence care for approximately 24 hours, as documented in the resident's bowel and bladder diary. The documentation showed a significant gap between care events, with the resident found wet with a bowel movement after this period. The care plan required staff to check and document incontinence status upon rising, after meals, at bedtime, and as needed, every shift, but this was not followed. Additionally, interviews with three alert and oriented residents who were dependent on staff for incontinence care revealed ongoing concerns about untimely care. One resident reported having to remain in a saturated brief until morning on multiple occasions, while another described poor call bell response and negative staff attitudes. A third resident stated they developed a yeast infection due to improper changing. Two residents and their family members reported making multiple complaints to the facility, but stated that no changes had occurred in response.
Plan Of Correction
1. Identified Residents had no negative outcome from not receiving ADL care. 2. Director of nursing or designee audited current residents to ensure ADL was provided for the past seven days. 3. Audits will be conducted by the Director of Nursing/designee of ten random residents who require ADL assistance to ensure they received care and will audit their documentation to ensure it reflects accordingly, weekly x 4 and then monthly x 3. Education will be provided to facility nursing staff regarding the Nursing Policy Activities of Daily Living (ADLs) and nursing assistant shift responsibilities. 4. Results of the audits will be reported to the QAPI committee.