Failure to Provide Incontinence Care Each Shift for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure incontinent care was provided at least once every shift for multiple residents who were incontinent of bowel and/or bladder. Five residents with varying degrees of cognitive impairment and dependence on staff for toileting had care plans and bowel/bladder assessments indicating they were always or frequently incontinent and required staff assistance and incontinence care as needed. Certified Nursing Assistant (CNA) bowel and bladder documentation showed that incontinent care was not consistently provided every shift, and on some days there was no documented incontinent care at all. For one resident with severe cognitive impairment, hemiplegia, aphasia, and benign prostatic hyperplasia, CNA documentation showed incontinent care was provided only one of two shifts on multiple dates and not at all on two specific dates. Another resident with Parkinson’s disease, dementia, chronic kidney disease, and benign prostatic hyperplasia, who was always incontinent per assessment and frequently incontinent per MDS, also had incontinent care documented only one of two shifts on multiple dates and no incontinent care documented on one date. A third resident with Type II diabetes, dementia, and hypertension, assessed as always incontinent but occasionally incontinent per MDS, had incontinent care documented only one of two shifts on numerous dates and no incontinent care documented on one date. A fourth resident with dementia, osteoarthritis, and chronic pain syndrome, assessed and care planned as frequently incontinent and needing assistance with toileting, had incontinent care documented only one of two shifts on several dates. A fifth resident with Type II diabetes, acute kidney failure, and anorexia, assessed as always incontinent and frequently incontinent per MDS, had no incontinent care documented on two dates and only one shift of incontinent care documented on several other dates. An anonymous resident reported there was not enough staff and that residents were not checked frequently for incontinence, stating that after complaining once, staff refused to provide care and incontinence care was not provided for 17 hours. The DON confirmed that CNA documentation showed incontinent care was not being provided every shift for the identified residents and could not verify that care had been provided. A family member of one resident reported finding the resident frequently incontinent and stated that their request for checks and changes every two hours was not being carried out.
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