F0677

D

Failure to Provide Timely Incontinence Care and Repositioning

Wheeler, Oregon Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinent care and repositioning assistance to a dependent resident over a seven-hour period. The resident had diagnoses including cancer and was on hospice, with a care plan indicating mixed bladder incontinence and dependence on staff for toileting. The care plan directed staff to check and change the resident during repositioning, as needed, and throughout the shift, and also documented a pressure injury to the coccyx with instructions for turn/repositioning at least every two hours and more often as needed. On the day in question, a CNA assigned to the resident did not provide incontinent care or repositioning for approximately seven hours of her shift, despite being responsible for these cares.

Interviews and the facility’s investigation showed that the CNA acknowledged she had only looked at the resident’s brief early in the shift, thought it appeared dry, and left it unchanged, and that she did not reposition the resident because the resident grimaced in pain when she pulled on the pad. Other CNAs reported that the CNA wrote a note on the CNA message board asking others not to let the nurse enter the resident’s room because the resident had not yet been changed, and that it was obvious to staff later in the shift that the resident had not been changed. The charge nurse became aware near the end of the shift that the resident had not received care, and other CNAs were asked to assist with completing the resident’s cares. Staff interviews confirmed that standard practice was to provide incontinence care and repositioning at least every two hours or according to the care plan, and the administrator acknowledged that the resident was not provided ADL assistance by the CNA for a prolonged period of time.