Failure to Inform and Educate Residents on Incontinence Product Changes
Penalty
Summary
The facility failed to adequately inform and educate residents regarding a change in incontinence treatment and products. Two residents experienced a switch from their previous incontinence products to smaller, reusable liners without receiving a clear explanation or individualized education about the reasons for the change. One resident expressed frustration and sadness, noting increased accidents and dissatisfaction with the new products, while another questioned whether they could purchase their preferred products independently. Both residents reported that staff did not provide sufficient information about the change, and documentation confirming resident education was not available. Staff interviews revealed that the facility had discussed general information about skin breakdown and moisture management during a resident council meeting, but there was no evidence of individualized education or documentation provided to the affected residents. Review of care plans and physician orders indicated that residents had preferences for certain incontinence products, but the facility did not document any education or risk/benefit discussions related to the new products. The lack of communication and documentation led to resident frustration and a lack of understanding about their care changes.