Failure to Provide Adequate Incontinent Care Supplies and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide adequate incontinent care supplies during the night shift for four of five sampled residents, resulting in residents not being treated with dignity and respect. Staff interviews revealed that residents were only given a set number of incontinence briefs each morning, typically six for a 24-hour period, and if these ran out before the next distribution, staff were instructed to 'bridge' residents using pads and bedsheets instead of briefs. Multiple staff members, including CNAs and LPNs, confirmed that they did not have access to additional briefs during the night shift, and that the environmental room where extra briefs were supposed to be stored was found to be empty during the surveyor's observation. Residents directly affected by this practice expressed discomfort and distress. One resident, who was severely cognitively impaired and frequently incontinent, was observed lying in bed with only a sheet covering his lower body and no brief on. Another resident, moderately cognitively impaired and always incontinent of bowel, reported that staff did not ask for her preference and simply used a sheet when briefs ran out, which she disliked but felt powerless to contest. A cognitively intact resident with a suprapubic catheter and bowel incontinence stated that briefs often ran out and staff would search other rooms for supplies, but sometimes resorted to using sheets, which he found unacceptable. Another cognitively intact resident with bowel and bladder incontinence described feeling anxious and stressed at night due to the lack of briefs, stating that she tried not to move to avoid urinating on a bedsheet and that the situation caused her mental anguish. Facility policy review indicated that residents have the right to receive adequate and appropriate health care and to be treated with dignity and respect. However, interviews with staff and the DON confirmed that the practice of limiting briefs and using 'open air' or bridging was implemented without consulting residents about their preferences. The DON acknowledged that non-cognitive residents were not provided briefs at night and that there were no extra briefs available in the locked room on the morning of the survey. Housekeeping and supervisory staff also confirmed the practice of distributing a fixed number of briefs and the lack of access to additional supplies during the night shift.