Failure to Provide Timely Incontinent Care and Change Soiled Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and change soiled linens for a resident who required assistance with activities of daily living. Surveyors observed a strong urine odor and an overly urine-saturated brief in the trash can in the resident’s room in the early afternoon. The resident’s bed had a visible wet ring in the center of the mattress, and the blanket, sheet, and cloth pad that had been removed from the bed and placed on the floor were wet. The facility’s perineal care policy required staff to provide perineal care in accordance with standards of practice to prevent skin breakdown and infection, dispose of used supplies, perform hand hygiene, and apply a new brief and change linens as needed. The resident’s admission assessment showed the resident was cognitively intact, occasionally incontinent of bladder, required partial/moderate assistance with toileting, and was dependent for bed mobility. The resident stated they were not soiled and reported staff had gotten them out of bed just before lunch. A CNA reported that when they went to the room around 1:00 p.m. or earlier to get the resident out of bed for therapy, the resident was wet, and the CNA changed the resident’s clothes but did not make the bed afterward. The CNA verified the sheet and linens were wet. The DON stated that staff were expected to check incontinent residents at least every two hours, clean and dry them if soiled, and change linens as needed when soiled, and confirmed observing the wet linens and wet ring on the resident’s bed.
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