Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living (ADLs) for residents who were unable to care for themselves. One resident, lying in bed on a low air loss mattress, reported being incontinent and currently wet and was unsure of the last time he had been changed, estimating it may have been around 7:00 AM. When a CNA began changing him at 9:39 AM, his incontinence brief was completely saturated with foul-smelling urine, and the CNA did not know when he was last changed, stating that if the night shift CNA had last changed him, it was probably around 6:00 AM. Deep grooves and indentations from the brief were observed in his thighs and groin area, with redness and inflammation noted on the left thigh, and a dried ring of urine was seen on the fitted sheet, prompting a full linen change. This resident’s assessment and care plan documented that he was dependent on staff for personal hygiene, bed mobility, toileting, and transfers, and required assistance with ADLs as needed. Another resident, also on a low air loss mattress, was observed at 10:15 AM when a CNA came in to change him and stated she did not know the last time he had been changed and had not changed him yet that day, explaining she had to get residents ready for breakfast and feed this resident. When the CNA removed the incontinence brief, the front and back were saturated with foul-smelling urine, and the resident did not assist with turning. The care plan for this resident showed bowel and bladder incontinence, frequent bladder incontinence, impaired mobility related to limited ROM, and required total staff assistance for toilet use, with instructions for staff to check and change him, including full perineal care, every two hours and as needed. Both CNAs and the DON stated that residents are supposed to be checked and changed at least every two hours and as needed, and the facility’s Incontinent and Perineal Care Policy required rounds at least every two hours to check for incontinence during each shift, which was not followed in these instances.
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.