F0677

E

Failure to Provide Timely Incontinence Care and Hygiene for Multiple Dependent Residents

Houston, Texas Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically incontinence care and related hygiene, to multiple dependent residents during the overnight shift. Several residents were care planned to be checked for incontinence at least every two hours, yet family reports and video evidence indicated that incontinent care was not provided for extended periods. Resident #2, a female with dysphagia following a stroke, was documented as always urinary incontinent and dependent for toileting hygiene, with a care plan directing checks for incontinence at least every two hours. Her family member reported that on one occasion there were 14 hours during which she was not changed, from approximately 9 p.m. one night until the following day, and stated that this was part of an ongoing issue with overnight staff not checking and changing residents.

Resident #3, a female with dementia but intact cognition per BIMS, was also documented as always urinary incontinent and dependent for toileting hygiene, with a care plan requiring checks for incontinence at least every two hours. Although observations during the survey found her clean, dressed, and without foul odors, she stated that her care was terrible and that there was not enough help. She reported that staff on the second and third shifts would shift responsibility to each other and that she had problems with the overnight shift not checking or changing her. She indicated that the overnight shift failed to check on her about three to four times a month, depending on which staff were working.

Resident #4 and Resident #5, both females with dementia and always urinary incontinent, were also dependent for toileting hygiene and had care plans directing checks for incontinence at least every two hours. For Resident #4, a grievance from a family member alleged that she was not provided incontinent care on the 11 p.m. to 7 a.m. shift, and the family member reported that camera footage showed she was not changed for 14 hours and 37 minutes between a diaper change at 10:04 p.m. and the next change the following day. For Resident #5, a grievance and family interview indicated that she was put to bed in the evening and not checked or changed throughout the night, with camera footage and family notes indicating a gap of nearly 14 hours or more between diaper changes. Video review provided by a family member showed staff presence in the shared room at 10:04 p.m. and then not again until midday the next day, with no documented incontinence care during the overnight hours. The facility’s own incontinent care policy required monitoring by rounds every two to three hours per shift, which was not followed in these instances.

Staff interviews further described the circumstances around these events. The daily staffing sheet for the 11 p.m. to 7 a.m. shift listed CNA B on the unit with these residents, but did not specify room assignments. CNA B stated she was new, received a written list of residents from another CNA, and was not aware of an assignment list at the nurses’ station that included additional residents. She reported that she provided care and vital signs to the residents she believed were assigned to her and denied neglecting any residents. Other CNAs working day shifts reported that residents were generally clean when they arrived and that night shift staff typically began changing residents around 5–6 a.m., and they denied current concerns about neglect. The DON acknowledged awareness that Resident #4 and Resident #5 were not changed on the night in question and described that CNA B had not looked at the assignment list at the nurses’ station. The facility’s incontinent care policy, last reviewed 6/6/25, specified that incontinent monitoring would be conducted by rounds every two to three hours per shift, which contrasted with the extended periods without incontinence care reported and documented for these residents.