Failure to Provide Incontinence Pads for Resident with High Care Needs
Penalty
Summary
The facility failed to ensure that incontinence pads were available for a resident who required them at all times. The resident, who was admitted with diagnoses including acute kidney failure, morbid obesity, and urinary retention, was cognitively intact and required substantial to maximal assistance with toileting, being always incontinent. The care plan identified the resident as being at risk for pressure ulcers due to incontinence and limited mobility. Despite these needs, the resident reported that on multiple occasions, incontinence pads in the appropriate size were not available, and staff substituted a draw sheet, which caused discomfort, especially after bowel movements. The resident also stated that after showers, he was left without an incontinence pad and had to sit in urine for extended periods. Observations and interviews with staff confirmed that incontinence pads were not available in the central supply closets on multiple floors, and the Central Supply Manager acknowledged being out of stock. The supply manager explained that orders were placed weekly based on census and budget constraints, which often made it difficult to maintain adequate supplies. Both the DON and the Administrator confirmed that incontinence supplies should always be available for all residents, but at the time of the survey, this was not the case for the resident in question.