Failure to Provide Timely Incontinent Care Resulting in Saturated Bed Linens
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of activities of daily living related to hygiene, grooming, and incontinent care for one cognitively intact resident. The resident, an older female with multiple medical diagnoses including cerebral infarction, COPD, dysphagia, DM2, bipolar disorder, heart failure, hyperlipidemia, CKD stage 3, and seizures, was dependent for peri-care/toilet hygiene, bed mobility, transfers, and lower body dressing, and was incontinent of bowel and bladder. Her care plan and physician orders reflected incontinence, diuretic use, and risk for skin breakdown, with topical Nystatin ordered for yeast infection in the groin and abdominal folds. The DON stated an expectation that nursing staff round at least every two hours to ensure incontinent care needs are met. On one date, the resident reported she had been left in a soiled brief for over five hours, resulting in bed linens saturated with urine. The Ombudsman corroborated that on that date, at approximately late morning, she found the resident crying and “soaking wet,” and allowed the resident to call the state hotline. The Ombudsman reported notifying the ADON and observing aides enter the room to provide peri-care while she spoke with the ADON. On a later observation date, the resident told the surveyor she was soiled with urine and waiting to be changed; the surveyor noted a slight urine odor and a brief that was not saturated and appropriately sized, and also noted the resident’s call light was not on during that interview. Staff interviews showed that CNAs, hospitality aides, an LVN, the ADON, and the DON all acknowledged the resident used XXL briefs kept in her room and typically used the call light when she needed to be changed. Multiple staff members, including CNAs and hospitality aides, stated they did not recall the resident being found soaked or excessively wet, and one CNA working the relevant hall on the date in question stated she was rushed but felt she completed her tasks, though she could not recall how often she checked on the resident. The DON and Administrator both stated expectations that incontinent care be provided as needed and that staff round at least every two hours, but the nurse aide task documentation for the date in question only showed incontinent care checked off by shift without indicating the number of times peri-care was provided. No facility incontinent care or ADL policy was reviewed prior to survey exit. The facility failed to ensure incontinent care was provided every two hours as recommended, resulting in the resident’s bed linens being saturated with urine.
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