F0677

D

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

Louisiana, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living for two dependent residents, resulting in prolonged exposure to urine and poor hygiene. Facility policy required that residents unable to perform activities of daily living receive necessary services to maintain grooming and personal hygiene. Resident #1’s MDS and care plan documented heart failure, kidney disease, dementia, moderate cognitive impairment, total bowel and bladder incontinence, dependence on staff for toileting hygiene and lower body dressing, use of briefs, and the need for skin cleansing, drying, and barrier cream after each incontinent episode, with checks every two to three hours and as needed.

On the survey date, Resident #1 was observed in bed with a strong urine odor in the room. CNAs removed a urine-soaked brief and a saturated bed pad, and the resident’s skin showed imprints from the brief, a bright pink inflamed area on the left inner buttock, and macerated skin at the coccyx. The resident stated that his/her arms and legs did not work properly and that he/she depended on staff and did not like to be wet. CNA A reported starting the shift at 6:00 A.M., not completing walking rounds with the previous shift, and not changing the resident since the start of the shift, despite being informed by an LPN at 7:30 A.M. that the resident was wet and should be changed after breakfast. CNA A prioritized breakfast and did not change the resident until after 10:00 A.M. CNA B confirmed that walking rounds with the previous shift usually did not occur, was unsure when the resident was last changed, and acknowledged the resident was not checked or changed for over four hours, resulting in skin irritation. The LPN and DON both stated that incontinent residents should be checked every two hours and that four hours was too long, and that Resident #1 had recently been diagnosed with moisture-associated skin disorder to the buttock.

Resident #2’s care plan documented a communication problem related to a head injury, potential/actual skin impairment related to impaired mobility, bladder incontinence with use of disposable briefs, the need for perineal care after each incontinent episode to remain odor free, and total assistance with personal hygiene. The MDS showed traumatic brain injury, severe cognitive impairment, dependence on staff for activities of daily living, and constant bowel and bladder incontinence. On observation, the resident was in bed with a urine odor in the room, and CNAs removed a brief saturated with dark yellow urine and noted red imprints from the brief on the skin. CNA A stated that the first time the resident was checked and changed on that shift was after 10:00 A.M., and that getting residents up for breakfast was the priority, making two-hour checks difficult. CNA B again reported that walking rounds with the previous shift generally did not occur, was unsure when the resident was last changed, and acknowledged the resident, who had wounds, had not been changed for over four hours. The LPN and DON reiterated expectations for two-hour checks and walking rounds to determine when residents were last changed, and the Administrator stated that incontinent residents should be checked and changed every two to three hours or as needed and changed immediately when staff are aware of incontinence.