F0690

D

Failure to Provide Timely Incontinent Care and Maintain Continence Support

Richmond, Texas Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident who was continent on admission received services and assistance to maintain continence and appropriate incontinent care. The resident was an elderly female with diagnoses including anxiety, need for assistance with personal care, history of falls, osteoarthritis, and dementia, with a BIMS score of 3 indicating severely impaired cognition. Her quarterly MDS documented that she required substantial/maximal assistance with toileting hygiene and lower body dressing and was always incontinent of urine and bowel. Her comprehensive care plan identified an ADL self-care performance deficit related to cognitive deficit, dementia, and history of falls, with an intervention requiring staff participation with personal hygiene and oral care.

On the day of observation, the resident was seen sitting in a recliner and was alert to name but not place or time. When asked, she stated she believed her brief was wet but then said she did not know, and there was no urine odor at that time. A CNA reported that she had taken the resident to the bathroom about 30 minutes earlier and that the resident could stand with one-person assistance. At the surveyor’s request, the CNA assisted the resident to the bathroom via wheelchair. When the resident stood from the recliner, the back of her pants was observed to be wet. In the bathroom, when the CNA pulled down the resident’s pants, the resident was found to be wearing a pull-up brief over another brief, and the inner brief was heavily soiled with urine, although the resident’s skin remained intact.

The CNA stated that the resident was a “heavy wetter” and that it was the resident’s family member who had double briefed her. The CNA said she only took the family member to the bathroom and that the family member had taken the resident to the bathroom, and she did not check the resident to see if she required incontinent care or needed to use the bathroom. The CNA reported that she typically checked on residents needing assistance every 1½ to 2 hours and acknowledged the importance of providing incontinent care at least every 2 hours to avoid rashes and soiled clothing. The resident’s family member later reported that she had taken the resident to a dental appointment, returned her to the facility late morning, took her to the bathroom, and double briefed her at the resident’s request because the resident did not want her clothes to get wet. The family member also stated that she often did everything for the resident when present, had concerns that staff did not change the resident’s brief in a timely manner, and had previously reported to the facility that staff sometimes did not enter the room for hours to change the resident. The ADON stated that even when a family member says they will take a resident to the bathroom, staff should follow up to ensure the resident’s needs are met and that incontinent care should be provided at least every 2 hours, consistent with facility policies on incontinence and quality of life.