F0690

D

Failure to Provide Timely and Complete Incontinence Care for Two Residents

Oregon, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely and effective incontinence care to two residents. One resident with paraplegia, chronic osteomyelitis, two stage IV pressure ulcers, urinary incontinence, and dependence on staff for ADLs had a care plan that included monitoring for UTI signs and providing incontinence care as needed. During observed incontinence care, a CNA removed a urine- and bowel-movement–soiled brief, cleansed only the fecal matter, applied a new brief, and did not cleanse the resident’s anterior perineum of urine. The CNA confirmed in interview that the urine was not cleansed from the anterior perineum during this incontinence care episode.

Another resident, in a persistent vegetative state, severely cognitively impaired, incontinent of bowel and bladder, dependent for all ADLs, and at risk for pressure ulcer development, had a care plan intervention to provide incontinence care as needed. Two CNAs were observed to perform incontinence care and reposition the resident, after which the resident remained on his back for several hours. From the time of that care until late morning, no staff were observed checking the resident for incontinence needs. When an LPN later entered the room and exposed the G-tube site, the resident was found to be heavily soiled with urine in the brief, but the LPN did not address the incontinence at that time and proceeded only with G-tube care. The resident was not changed until nearly an hour later, when two CNAs entered, found the resident heavily soiled with urine, and then provided cleansing and repositioning. Staff interviews indicated residents were to be checked, changed, and repositioned every two hours, and the DON stated there was no written policy, with incontinence care considered a standard practice task.