F0677

D

Failure to Provide Timely ADL, Incontinence Care, and Repositioning for a Dependent Resident

Houston, Texas Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and necessary ADL care, including repositioning, incontinence care, and a scheduled bed bath, to a dependent resident. The resident was a 57-year-old female with acute respiratory failure with hypoxia, morbid obesity, and paralytic syndrome following cerebral infarction. Her MDS showed intact cognition (BIMS 14), total dependence on staff for all ADLs, and always-incontinent bladder and bowel status, with identified risk for pressure ulcers. Her care plan required that she remain clean, dry, odor-free, and well-groomed, with total assistance of two staff for toileting and personal hygiene, extensive assistance of two staff for bed mobility and dressing, and routine sponge baths when a full bath could not be tolerated. The shower/bathing schedule showed she was to receive a bed bath on the day shift, and facility policies required assistance with bathing, ADLs, and turning/repositioning every 2–4 hours.

On the cited date during the 6:00 AM–2:00 PM shift, CNA documentation did not show that the resident received repositioning, incontinence care, or her scheduled bed bath. The resident reported that she had requested assistance earlier in the morning to have her soiled brief changed and to receive a bed bath, but the care was not provided. She stated she later informed another CNA of her need for a brief change and continued to wait, and that there were days when she called for assistance and no staff came, and days when no one checked on her until approximately 6:00 PM. She further stated she had not been repositioned even once during the morning shift, that staff including a nurse, the DON, and CNAs had checked in on her but did not reposition her, and that she was supposed to receive a bed bath that morning but was not offered one. She denied skin breakdown related to the delayed care.

Nursing staff interviews confirmed that the ordered care was not provided during the morning shift. A nurse stated he reminded the assigned CNA multiple times during the shift to provide the bed bath and that the CNA assured him it would be completed before shift end; later, the CNA told him she had arranged for another CNA to help with the bed bath. The CNA assigned to the resident admitted that during her 6:00 AM–2:00 PM shift she did not reposition the resident, did not provide incontinence care, and did not provide the scheduled bed bath, despite the resident informing her of the need for a change. She acknowledged the resident required 2–3 staff for care, stated she did not ask for assistance during the shift, and said she planned to provide care after lunch during the following shift. The DON stated that dependent residents were expected to be repositioned at least every two hours and that staff had been trained on incontinence care, repositioning, and ADLs, and confirmed he was not informed that the required care had not been provided. Later observation of care showed removal of a wet brief and a bed bath with intact skin and no pressure injuries noted.