Failure to Provide Adequate Incontinence Care and Maintain Resident Cleanliness
Penalty
Summary
The facility failed to provide appropriate urinary incontinence care and maintain resident cleanliness for multiple residents on the [NAME] Hall. During observations conducted over several days, surveyors noted a consistent, distinct, and moderately offensive urine odor in the [NAME] Hallway, with the odor more pronounced in the rooms of several identified residents. Some of these rooms contained hand-held plastic urinals. The urine odor persisted on subsequent observation days and was again noted in the hallway and around specific resident rooms. One cognitively intact resident reported that staff did not wipe her clean when changing her incontinence undergarments, stating that staff removed the wet brief and applied a dry one without cleansing her, which resulted in her smelling like urine and put her at risk for skin breakdown. Her care plan documented that she was at risk for skin impairment, required staff assistance for toileting hygiene, and needed barrier skin protection cream after incontinence episodes. A registered nurse reported that agency staff had been changing residents’ incontinence undergarments but leaving absorbent pads on the bed soaking wet, which contributed to urine odor permeating from resident rooms into the hallways.
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