Failure to Follow Resident-Centered Incontinence and Skin Integrity Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow an individualized, resident-centered care plan for a resident with multiple medical conditions, including COPD, hereditary and idiopathic neuropathy, and back muscle spasms. The resident’s MDS dated 3/13/2026 showed that the resident was cognitively independent for daily decision-making but dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s care plan for potential/actual impairment to perineal skin integrity related to MASD, initiated 11/20/2025, directed staff to keep the resident’s skin clean and dry. A separate care plan for a UTI, revised 2/14/2026, directed staff to check the resident for incontinence at least every two hours and to wash, rinse, and dry soiled areas. On 3/4/2026 at 11:45 a.m., a CNA reported that the resident’s last brief change had been at 8:00 a.m. and, upon checking, found the resident’s brief to be wet but stated the resident would be changed after the CNA’s lunch. The RN Supervisor later stated the resident was changed at 1:00 p.m., indicating the resident remained in a wet brief beyond the two-hour incontinence check interval specified in the care plan. During interviews and record review at 2:00 p.m., the RN Supervisor confirmed that, according to the resident’s care plans, staff were required to keep the resident clean and dry and to check for incontinence every two hours, and acknowledged that the care plan was not being followed. The facility’s policy on Comprehensive Person-Centered Care Plans, revised 3/2022, stated that the comprehensive care plan describes services to attain or maintain the resident’s highest practicable well-being. The DON stated residents should be changed every two hours and that if the care plan indicated to keep residents clean and dry and to check every two hours for incontinence, it should be implemented by staff.
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.