Failure to Provide Timely Incontinence Care, Hygiene, and Dignified Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living, incontinence care, and hygiene for a cognitively impaired resident, resulting in the resident being left undressed from the waist down and lying on urine-soiled linens for several hours. The resident had diagnoses including Alzheimer’s disease, dementia, major depressive disorder, and difficulty walking, and assessments documented that she lacked decision-making capacity, had severely impaired cognition, and required moderate assistance for toileting, bathing, dressing, personal hygiene, sit-to-stand mobility, and toilet transfers. Care plans identified her as being at risk for skin breakdown and urinary tract infection related to occasional bowel and bladder incontinence, with interventions directing staff to check her at least every two to three hours for incontinence, provide perineal care after each episode, and change clothing and linens as needed. On the morning of the survey observation, the resident was found in her room with the door closed and strong air blowing from the vents, stating she was cold. She was observed wearing only a thin blue shirt and was undressed from the waist down, without briefs or underwear. Her bed sheets were soiled with yellowish stains, which were covered by a towel and a chucks pad. Later that day, during a concurrent observation and interview, the resident remained undressed from the waist down on the same soiled linens covered with a towel and chucks pad. The CNA assigned to the resident acknowledged she had not checked on the resident since the start of her shift at 7 a.m. and stated that the towel and chucks pad had been placed by the previous shift. The CNA stated it was not appropriate for the resident to be left lying on soiled linens without a brief and undressed from the waist down, and acknowledged that leaving the resident unattended on wet, soiled linens was unsanitary and could affect the resident’s dignity, comfort, and emotional well-being. The LVN assigned to the resident stated the resident should not have been left undressed from the waist down or lying on soiled, wet linens, and acknowledged that the resident had remained unchecked for approximately five hours, despite the LVN having passed medications at 9 a.m. without checking the resident’s condition. Review of the bathing schedule and ADL bathing flow sheet for that day showed the resident had been scheduled for a shower that morning but did not receive it because the CNA was running behind, and the LVN did not assist or report the delay, despite stating it was her responsibility to do so when nursing assistants were behind. These events occurred despite facility policies requiring prompt cleansing after incontinence, maintenance of personal hygiene and ADLs, treatment with dignity and respect, and prompt attention to soiled linens in order to maintain a clean, sanitary, and comfortable environment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.