Failure to Provide Timely Incontinence Care and Repositioning for Dependent Residents
Penalty
Summary
The facility failed to provide timely incontinence care and repositioning services for three dependent residents who required assistance with activities of daily living (ADLs). Observations and interviews revealed that these residents, all of whom had significant cognitive and physical impairments, were not repositioned or provided incontinence care as required. For example, two residents were observed sitting in the dining room for approximately three hours without being repositioned or toileted, despite being dependent on staff for these needs. One resident, who was always incontinent of bowel and bladder and dependent for all ADLs, was observed in her wheelchair throughout the day without being changed or repositioned from the time she was gotten up for breakfast until late afternoon. Both the resident and the CNAs confirmed that she had not been changed or laid down during this period. Staff interviews indicated that delays in meal service frequently disrupted the regular schedule for turning, repositioning, and providing incontinence care, resulting in residents not receiving care every two hours as expected. Multiple CNAs and supervisory staff acknowledged that the affected residents were incontinent and required assistance with turning and repositioning. Staff also stated that late meal service often interfered with their ability to maintain the required care schedule. The facility's policy required repositioning and skin care every two hours, but this standard was not met for the residents in question. The facility did not provide a policy specifically regarding ADL care to the surveyors.