Failure to Provide Correct Size Incontinence Briefs During Supply Shortage
Penalty
Summary
The facility failed to provide the correct size incontinence briefs for three residents who were either frequently or always incontinent of bowel and/or bladder. According to Minimum Data Set (MDS) assessments, all three residents had intact cognition and required 3X size incontinence briefs due to their body size and high urine output. Due to a shipment error and ongoing supplier issues, the facility experienced a shortage of 3X briefs, resulting in staff using smaller 2X or XL briefs that were less absorbent and more difficult to manage. Certified Nurse Assistants (CNAs) reported that this shortage had persisted for weeks, and that they had informed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) multiple times. During the shortage, CNAs were instructed to use whatever sizes were available, even if they did not fit the residents properly. Residents reported discomfort, skin irritation, and concerns about skin breakdown due to the use of improperly sized briefs. Multiple residents stated that the smaller briefs rubbed their skin, were less absorbent, and required more frequent changes. Staff interviews confirmed that the issue was ongoing and that residents were unhappy with the substitute briefs. The facility's own incontinence care guidelines require that briefs fit appropriately to maintain cleanliness, comfort, and prevent skin breakdown, but these guidelines were not followed during the supply shortage.