F0677

D

Failure to Provide Timely Incontinence Care Due to Meal-Time Restrictions and Inadequate Rounding

Fairlawn, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely toileting hygiene and incontinence care to residents who were dependent on staff, resulting in residents remaining in urine and feces for extended periods. One resident, admitted with a fracture of the right femur, muscle weakness, and a need for assistance with personal care, was documented as cognitively intact, frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene. Her care plan identified complete incontinence with an intervention to provide incontinence care as needed. She reported that staff sometimes did not change her when she was incontinent and made her wait long periods. She described an incident where, after she had an accidental bowel movement, a CNA told her it was mealtime and she would have to wait until after the meal to be changed.

On a subsequent observation, this resident was found lying in bed and reported she was wet with urine and had not yet been checked or changed that day, despite CNAs starting their shift at 6:00 A.M. Her primary CNA stated she had not yet checked the resident for incontinence and that she typically did her first rounds after breakfast, then again before lunch, for a total of about four checks in a 12‑hour shift. During observed incontinence care, the resident’s brief was saturated with urine, her peri area and buttocks were deep red, and she cried out in pain when the area was cleansed. Another CNA reported she routinely checked and changed residents only three times in a 12‑hour shift. Multiple staff, including CNAs and an LPN, stated they were not allowed to perform patient care, including changing residents, during meal service from the time the meal cart arrived until trays were picked up, and one CNA confirmed she had required a resident to wait to be changed during a prior mealtime because of this rule.

A second cognitively intact resident, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, also had a care plan indicating complete incontinence with interventions to provide incontinence care as needed. She reported that she had requested to be changed about an hour earlier after having a bowel movement, and that the CNA told her she would change her before bringing meal trays. Later, she stated she still had not been changed, her call light remained on, and she expressed being upset about having to sit in her bowel movement. The charge nurse confirmed both CNAs were feeding other residents and that it took a long time for staff to provide care. When the CNAs arrived, one CNA denied the earlier request, rolling her eyes, while the resident firmly restated that she had asked to be changed. Observation of peri care revealed the resident was saturated with urine and stool in the peri area, with a large bowel movement present and redness on the buttocks and thighs. The CNA wiped from the buttocks up through the vaginal area, revealing heavy stool with each wipe, and confirmed she only wiped the front twice in this manner. The DON later stated that staff were allowed to change residents during meals and that residents were to be checked and changed every two hours and as needed.