Failure to Provide Timely Incontinent Care and Hygiene for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically grooming and personal hygiene, to a resident who was incontinent of bowel and bladder. The resident had diagnoses including cerebral vascular accident, schizophrenia, and intellectual disability, and the MDS documented severe cognitive impairment, total assistance needs for personal hygiene, and total assistance of two staff for toileting. Despite these needs, the resident’s care plan and Kardex did not include a bowel and bladder incontinence care plan or specific instructions for incontinent care, and there was no documentation that the resident refused care. On the survey date, observations showed the resident in bed wearing only an incontinent brief, with a small blanket and a flat sheet that was visibly soaked with urine from the shoulders to the foot of the bed. Multiple soiled flat sheets and a soiled brief were found on the floor between the bed and the wall, along with a large amount of feces and dried food debris. The resident remained on the heavily soiled sheet for at least 40 minutes, during which time the lunch tray was delivered and fully consumed while the room and the resident’s bedding remained soiled. Later observation showed that although the bed linens had been changed, the dried food debris and large amount of feces remained on the floor behind the bed. Interviews confirmed that incontinent care was expected every two to three hours and that the resident should have been cleaned before receiving lunch. The CNA assigned to the resident stated they had provided incontinent care around 7:30 a.m., had not returned since, and acknowledged the resident should have been cleaned before lunch. Video surveillance showed that this CNA delivered the lunch tray shortly before 1:00 p.m., contradicting their initial statement that they had not provided the lunch tray. The RN Unit Manager stated the resident was incontinent and required total assistance, was unsure if the resident was care planned for incontinence, and confirmed that incontinent care should occur every two to three hours and before meals. A family member reported the resident was always soiled with feces and urine during visits, and the Corporate DON stated incontinent care should be completed every two to three hours and that the resident and room should have been cleaned before lunch, noting that the facility does not document ADL completion.
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