Observations:
Based on clinical record review, observations, and interview with staff, it was determined that facility failed to provide incontinence care in a timely manner for two residents out of 16 reviewed. (Resident R1 and R2)
Findings include:
Review of Resident's R1's clinical record revealed diagnosis of disorder of the skin and subcutaneous tissue, rash and other nonspecific skin eruption and resident R1 is care planned for "check resident approximately every 2 hours and provide incontinence care as needed".
Review of R1's minimum data set (MDS), completed on November 11, 2023, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident's cognition intact. Additional review of the MDS revealed that Resident R1 required 2 people assist for ADL's.
Review of R2's minimum data set (MDS), completed on October 30, 2023, revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Additional review of the MDS revealed that Resident R1 required 2 people assist for ADL's.
Interview with R1 on March 1, 2024, at 11:00 a.m. on the second floor in resident's room revealed that the resident was wet and was not changed from 5:00 a.m. today (this morning). Also reported that she called the call bell to be changed and is still waiting. Nursing Assistant, Employee E5 entered the resident's room at 11:15 a.m. and the resident asked if she could get change and the nursing assistant replied if it could be done after lunch. Resident said no because she been waiting from 5:00 a.m. to get change and would like to be changed.
The Resident's roommate, Resident R2 also reported that it happens sometimes with staff not changing her in a timely manner, for example last night the 11-7 shift staff didn't want to change her.
28 Pa Code 201.29(j) Resident rights
28 Pa Code 211.11(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/20/2024
1. Resident #1 received incontinence care in accordance with plan of care on 03/01/2024 by the CNA. Follow-up was completed with Resident #1 by the licensed nurse with no further complaints regarding incontinence care or adverse effects noted.
Resident #2 received incontinence care in accordance with plan of care on 03/01/2024 by the CNA. Follow-up was completed with Resident #1 by the licensed nurse with no further complaints regarding incontinence care or adverse effects noted.
2. An audit of current residents who are incontinent was completed to validate that incontinence care had been provided timely per plan of care and/or resident request. Variances were addressed at the time of the audit.
3. Nursing staff will be re-educated on the importance of completing timely incontinence care per plan of care and/or resident request.
4. The DON/designee will complete 15 random audits of incontinent residents for completion of timely incontinence care per resident plan of care or as requested weekly for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
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