F0677

D

Failure to Provide Timely Incontinent and ADL Care

Natchitoches, Louisiana Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The facility failed to provide timely assistance with activities of daily living, specifically incontinent care, to a resident who was fully dependent on staff. The resident had multiple diagnoses including Type 2 Diabetes Mellitus, quadriplegia, essential hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, and had an admission MDS BIMS score of 15 indicating intact cognition. Her care plan, reviewed on 03/04/2026, identified an ADL self-care performance deficit related to impaired mobility and included interventions such as responding to call lights promptly and providing perineal care every two hours and as needed. Despite these documented interventions, the resident reported that staff did not respond to her call bell in a timely manner for incontinent care.

The resident stated that she began requesting incontinent care assistance at 2:30 a.m. and was not changed until between 7:00 a.m. and 7:30 a.m., and that staff sometimes entered her room, turned off the call light, and left without providing care. She reported using an Alexa device to track the time and stated she had notified several staff members, including the administrator, about these delays. The Social Services Director confirmed that the resident had filed three grievances in the last three months, two of which involved call bell response times related to incontinent care. An LPN and a CNA both reported that the resident had informed them she was not being cared for in a timely manner, and the ombudsman also reported that the resident had complained of not being bathed and changed in a timely manner. These observations and interviews demonstrated that the facility did not follow its own policy and care plan interventions to ensure timely ADL and incontinent care for this resident.