F0690

D

Failure to Provide Timely Incontinence and Adequate Catheter Care

Cleveland, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The facility failed to provide timely incontinence care to Resident #64, who was admitted on 10/05/21 with diagnoses including muscle weakness, lack of coordination, and diabetes. The resident had intact cognition, was non-ambulatory, dependent for transfers and bed mobility, and was incontinent of bowel and bladder. The care plan dated 12/22/25 indicated the resident was dependent with toileting and required staff assistance with ADLs, including checking for incontinence, offering toileting assistance, and removing wet or soiled clothing to provide incontinence care. On 02/19/26 at 1:59 P.M., the resident reported he was incontinent of urine, had asked to be changed, and had not been changed since the previous evening. He stated he had recently asked a CNA for incontinence care, but the CNA told him she was going on break and would change him upon return. During the interview, a strong urine odor was noted. At 2:20 P.M., CNA #303 confirmed the resident had requested incontinence care prior to her break and that she told him she would change him when she returned. Observation of incontinence care at that time revealed the resident was heavily soiled with urine that had soaked through his brief, clothing, and onto his wheelchair. CNA #303 stated she had not provided incontinence care during her shift and was unaware he required care until he informed her shortly before.

The facility also failed to provide adequate catheter care to Resident #153, admitted on 01/30/26 with diagnoses including urinary retention, stroke with right-sided weakness, and muscle weakness. The care plan dated 02/01/26 identified the resident as being at risk for infection related to use of a urinary catheter, with interventions including Foley catheter care every shift. The MDS indicated intact cognition, dependence with toileting, and an indwelling urinary catheter, and current physician orders directed catheter care every shift and as needed. On 02/26/26 at 11:38 A.M., the resident was observed calling out for assistance and stated he was upset and lying in a dirty brief. At 11:48 A.M., CNA #409 reported having provided incontinence care approximately an hour earlier and was unaware the resident required additional care. CNA #409 then provided incontinence care due to stool incontinence, and further observation revealed a large amount of brown dried debris around the catheter tubing. CNA #409 stated he had not provided catheter care during the earlier incontinence care and was unsure when catheter care had last been provided.