F0677

E

Failure to Provide Timely Incontinence Care for Dependent Residents

Twinsburg, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinence care to dependent residents, contrary to its policy and stated expectations for two-hourly checks and changes. One resident with dementia, severe cognitive impairment, total dependence for transfers, toileting, and hygiene, and a care plan calling for toileting rounds and incontinence care as needed, was placed in a Geri chair after a hospice aide provided a morning shower and incontinence care around 9:00 A.M. The resident remained in essentially the same position across from the nurses’ station for several hours without being checked or changed. By approximately 2:00 P.M., when incontinence care was finally provided, the resident’s brief was found to be saturated, and staff identified a dressing on the buttocks with surrounding deep red tissue in the buttocks and coccyx/sacral area. The primary CNA stated no one had told her how often to check and change residents and that she typically relied on hospice to provide morning care and then tried to change residents after lunch and dinner.

A second resident, with hemiplegia, multiple contractures, a sacral pressure ulcer, total dependence for toileting hygiene and transfers, and a care plan directing staff to check continence, assist with toileting, and provide incontinence care when wet or soiled, was observed during wound care with a brief that was wet with urine. The bed sheets under this resident were peppered with crumbs and flaking skin cells, which were verified by nursing staff. During the wound care procedure, the resident was turned, the soiled brief was opened to access the sacral wound, and the wound was measured and treated. After treatment, the same saturated brief was refastened, and the involved nursing staff left the room without changing the brief or notifying other staff that the resident was wet.

Later that morning, when CNAs provided incontinence care to the second resident, the brief was again confirmed to be saturated with urine, and the bed sheets remained covered with crumbs and dried skin cells. The primary CNA for this resident reported that her shift began at 7:00 A.M., that this was the first time she had checked and changed the resident that shift, and that the resident required two staff for turning, which she stated was difficult due to lack of available help. Another LPN acknowledged that residents were not being changed timely and that there were many heavy-care residents. The MDS RN, DON, and Administrator all indicated that residents were expected to be checked, changed, and repositioned every two hours or as needed, and the facility’s urinary continence and incontinence policy described a “check and change” strategy at regular intervals to maintain dignity, comfort, and skin protection. Despite these expectations and policies, the observed care for both residents did not meet the stated standards for timely incontinence care.