Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically incontinence care, to a resident who was dependent on staff for these needs. Facility policy on ADL support, revised in April 2025, states that residents who are unable to carry out ADLs independently are to receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The resident’s Quarterly MDS dated March 4, 2026, documented that the resident required a Hoyer lift and was dependent on staff for showering/bathing and toileting. On the survey date, the resident reported during an interview at 11:12 a.m. that they required assistance with incontinence care and had activated their call bell at approximately 11:00 a.m. At 11:17 a.m., a staff member entered the room, acknowledged the call bell, and, upon being informed that the resident needed incontinence care, stated they would inform the nurse aide. By 11:35 a.m., when the interview concluded, no staff had come to provide the requested care. Continued observation from the nurses’ station between 11:35 a.m. and 12:03 p.m. showed that no staff responded to the resident’s call for incontinence assistance during that period. When questioned, the DON stated that a 15-minute wait time for call bell responses was considered too long, while the resident had been waiting for over an hour.
Plan Of Correction
Resident 1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide audit of all residents who are dependent for toileting will be completed. Nursing staff will be educated on ASL policy. DON/Designee will complete ADL care audits daily x30 days then three times per week for 4 weeks to ensure proper ADL care is being provided. DON/Designee will report findings to QA Committee for review and recommendations.
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