F0725

E

Insufficient Nursing Staff Leading to Missed Incontinence Care and Delayed Medications

Westmont, Illinois Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ incontinence care and medication administration needs, resulting in missed or delayed care for multiple residents. One resident with a care plan identifying a stage 2 pressure sore on the left buttock and risk for further skin breakdown due to incontinence, impaired mobility, diabetes, and comorbidities reported not receiving incontinence care since getting out of bed in the morning. When a CNA provided care around midday, the resident was found wearing two incontinence briefs with a small amount of thick feces and blood in the brief, and excoriation of the buttocks, sacrum, scrotum, and a bleeding left abdominal fold. The CNA stated she routinely placed two briefs on this resident because she was responsible for many residents, could not always get back to him, and believed the extra brief would keep his clothes dry when he sat in a wet brief for extended periods.

Another resident with a care plan for bowel and bladder incontinence, including an intervention to clean the perineal area with each incontinence episode, was observed during incontinence care wearing two briefs that were saturated with urine and stool, with a large, reddened scrotum. The CNA providing care stated the double briefs had been applied by the previous shift and acknowledged that residents should not wear two disposable briefs at the same time because it was bad for their skin. The DON later stated that residents should not have two briefs on unless this was a care-planned preference and that double-briefing could lead to skin breakdown and UTIs if not changed, while facility policy required residents to be checked periodically for incontinence and provided appropriate perineal/genital care.

Multiple cognitively intact residents reported that medications, including routine and PRN pain medications, were often late and that nurses told them they were busy and would give medications when they could. Medication administration records showed repeated delays beyond the facility’s policy requirement that medications be administered within one hour of prescribed times. One resident council president reported complaints from residents about late medications, long call light response times, and insufficient staff; their MAR showed numerous medications scheduled for late afternoon and evening being given more than an hour late on several days. Other residents reported late blood glucose checks and insulin administration, with documentation showing insulin and other medications given one to several hours after scheduled times. One resident stated their blood glucose check was delayed because the nurse lacked testing strips and had to obtain them from another area, and that insulin ordered for early evening was not given until later at night.

Additional residents described waiting more than two hours for medications and feeling there were not enough nurses to pass medications when needed. MAR reviews for several cognitively intact and severely cognitively impaired residents showed repeated late administration of ophthalmic medications, creams, oral medications, blood glucose monitoring, and insulin, often one to two hours after scheduled times. Resident council minutes over several months documented ongoing concerns about call light response times, inconsistent follow-up, and staff turning off call lights before providing requested assistance. Staff interviews revealed that one LPN was responsible for 32 residents on a floor that previously had 25 residents, and CNAs reported working with only two CNAs for 30 residents, including many with mechanical lifts, feeding needs, and dialysis schedules. The DON confirmed that the first floor, with about 30 residents, was staffed with two CNAs and one nurse on all shifts, despite the facility assessment and staffing policy stating staffing should be based on census and acuity to ensure sufficient staff to meet residents’ care needs.