Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Staff failed to respond timely to a resident’s need for assistance with activities of daily living, specifically incontinence care. A facility-reported incident documented that on 6/5/25 at 8:40 a.m., a staff member found resident #99 lying in bed in urine-soaked clothing and a soiled brief. This was discovered by day shift staff members O and L after they completed shift change report with NF3, the night shift staff member responsible for the resident’s care. During interview, staff member L stated that NF3 did not report that the resident needed his brief and clothes changed and that it was not normal routine to leave a resident in a soiled brief or clothing. Resident #99’s MDS, with a quarterly assessment reference date of 5/14/25, showed he required partial/moderate assistance for lower body dressing and toileting hygiene and was frequently incontinent of bladder and bowel. His comprehensive care plan, initiated 3/24/25 for an ADL self-care performance deficit, included an intervention for staff to check him regularly for incontinence episodes and provide prompt peri-care after such episodes. The facility’s interdisciplinary team investigation identified a lapse in care by NF3 related to this incident, during which the resident remained in soiled clothing and a soiled brief without timely incontinence care.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.