F0835

E

Failure to Maintain Adequate Incontinence Supplies and Gloves for Resident Care

Marshall, Missouri Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

Facility administration failed to implement an effective system to ensure sufficient incontinence supplies and gloves were available to meet residents’ needs. The facility had no policy regarding maintaining sufficient supplies, and the census was 37. Observations on the day of survey showed multiple resident rooms without gloves and without appropriate incontinence briefs, despite care plans requiring the use of briefs and peri-care after incontinence episodes. Central storage rooms contained only small and medium incontinence briefs and pull-ons, while the posted resident list showed that no residents required small briefs and multiple residents required large, extra-large, triple extra-large, and quadruple/quintuple extra-large sizes, which were not in stock.

One resident with frequent urinary incontinence, who required staff assistance with ADLs and wore size five-X incontinence briefs, was observed without an incontinence brief and with only one brief two sizes too small available at bedside. There were no gloves in this resident’s room. The resident reported that incontinence supplies had been low for two months, that the facility was out of briefs in the correct size, and that he/she had gone without briefs when the facility was out. The resident stated staff had brought a brief two sizes too small that could not be worn, and described having multiple incontinent episodes over the previous two days, requiring clothing changes due to lack of briefs, and feeling humiliated when incontinent without a brief. The DON confirmed this resident had not had incontinence briefs for four days.

Another resident with some incontinence, whose care plan required assistance with toileting hygiene, peri-care, and use of incontinence briefs as needed, had no gloves or incontinence briefs in the room. This resident stated he/she wore briefs when the facility had them, went without when they ran out, and had been told that large briefs were unavailable that day, resulting in not wearing a brief. A third resident, frequently incontinent of bowel and bladder and care planned for peri-care with each brief change, also had no gloves or briefs in the room. This resident reported the facility had run out of his/her size briefs two weeks earlier, that staff had put on a brief that was too small, and that an incontinent episode the previous day required a clothing change because the brief was too small. Staff interviews corroborated that this resident’s correct size had been unavailable and that smaller briefs were used instead.

Additional observations showed no gloves in another resident’s room, with that resident stating staff brought gloves in their pockets when providing care. There were no gloves on the medication cart at the nurse’s station, and multiple occupied rooms lacked gloves, while boxes of gloves were kept at the nurse’s station. Multiple CNAs, CMTs, and an RN reported that since August the facility had ongoing issues with low supplies of gloves, incontinence briefs, and wipes, including running out of larger brief sizes. Staff stated residents sometimes went without briefs or were placed in smaller sizes, and that gloves were removed from rooms and kept at the nurse’s station when supplies were low, with staff carrying gloves in their pockets.

The DON stated she was responsible for ordering supplies twice a month and was supposed to complete daily inventory but actually did so every other day. She said staff were expected to report low supplies so that items could be purchased locally or increased on the next order, and that supply issues were discussed daily in morning meetings. She acknowledged she was not aware the facility was completely out of larger briefs until staff reported it on the survey date, and that when glove supplies were low, gloves were kept at the nurse’s station and staff were expected to take handfuls and keep them in their pockets or on carts, even though this was an infection control issue. The Administrator acknowledged ongoing issues with running low or out of supplies, attributed to higher usage of gloves and briefs and an insufficient established supply, and stated he relied on staff notification and morning meetings to monitor supply levels, and was aware that gloves and briefs were low on the survey date.