Failure to Provide Incontinence Products Compromises Resident Dignity
Penalty
Summary
The facility failed to provide appropriate incontinence products to four residents, resulting in a lack of dignity and embarrassment for those affected. Multiple residents with significant medical conditions, including pressure ulcers, diabetes, hemiplegia, and chronic kidney disease, reported that they were not provided with incontinence briefs, particularly at nighttime. Some residents stated that they were forced to wet themselves on bed pads or in their clothing, leading to feelings of embarrassment and discomfort. Residents also reported that staff refused their requests for incontinence briefs at night, and that the facility frequently ran out of the correct sizes, forcing them to use ill-fitting products or go without. Staff interviews confirmed that the facility had a recurring issue with running out of incontinence briefs, especially in larger sizes. Certified Nurse Assistants (CNAs) and supervisors stated that they had to inform the administrator when supplies were low, and sometimes had to use alternative sources or go without briefs for residents. Observations of storage areas revealed limited stock, with some sizes missing entirely. Staff also reported that the administrator instructed them not to use incontinence briefs at night unless specifically requested by alert residents, and that families of non-alert residents were not consulted about their preferences. The administrator cited concerns about skin breakdown as a reason for not using briefs at night, but acknowledged there was no physician order for this practice. Facility documentation, including grievance forms and resident council memoranda, showed ongoing concerns from residents about the lack of appropriate incontinence supplies, particularly larger sizes. The facility's own admission packet and dignity policy stated that incontinence care and supplies were to be provided to all residents as part of routine care. Despite these policies, the facility did not have a specific policy on incontinence care or supplies, and failed to address repeated grievances about the issue. This resulted in residents experiencing embarrassment, discomfort, and a lack of dignity due to inadequate incontinence care.