145339
03/12/2024
Grove of Elmhurst, The
127 West Diversey Elmhurst, IL 60126
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide toileting hygiene for residents who required assistance with incontinence care.
Residents Affected - Some This applies to 4 of 4 residents (R1, R4, R5, R6) reviewed for ADL's (Activities of Daily Living) in the sample of 6. The findings include: 1. On March 8, 2024, at 11:14 AM, V3 (CNA/Certified Nurse Assistant) assisted R1 to the resident bathroom. V3 lowered R1's pants and opened R1's incontinence brief. R1's incontinence brief had a second incontinence brief inside. At 1:45 PM, V3 stated some of the residents were heavy wetter's but the residents should only be wearing one incontinence brief. The EMR (Electronic Medical Record) shows diagnoses including paralytic syndrome, epilepsy, chronic kidney disease, type 2 diabetes mellitus, schizoaffective disorder, hypertension, gout, mild cognitive impairment, pain in unspecified joint, hearing loss, bipolar disorder, gastro-esophageal reflux disease, hydronephrosis, and obstructive and reflux uropathy. R1's MDS (Minimum Data Set) dated January 29, 2024, showed R1 had mild cognitive impairment. R1 required maximal assistance from staff personal hygiene and was dependent on staff for toileting hygiene. 2. On March 8, 2024, at 10:49 AM, V5 (CNA) was providing incontinence care to R4. V5 opened the yellow incontinence brief and there was another blue incontinence brief inside. V5 then said R4 asks to have two incontinence briefs. At 1:46 PM, V5 stated the resident should only be wearing one brief. V5 stated she complies with R4's request for two incontinence briefs because of customer service and to let them have their way. V5 stated the staff were supposed to provide incontinence care every two hours. V5 stated R4 wets heavy and that is why she applied two. The EMR shows diagnoses including left knee contracture, pain in left knee, osteoarthritis, major depressive disorder, dementia, hypertension, hepatitis B, and HIV disease. R4's MDS dated [DATE], showed R4 had severe cognitive impairment. R4 required maximal assistance from staff for toileting hygiene and was dependent on staff for personal hygiene. 3. On March 8, 2024, at 1:11 PM, V3 (CNA) provided incontinence care for R5. V3 removed R5's brief and there were two incontinence briefs in place. V3 stated there were two briefs on. V3 stated R5 was a heavy wetter so she put two briefs on him. V3 stated the last time she changed R5 was at 10 AM
Page 1 of 2
145339
145339
03/12/2024
Grove of Elmhurst, The
127 West Diversey Elmhurst, IL 60126
F 0677
and had applied two incontinence briefs at that time.
Level of Harm - Minimal harm or potential for actual harm
The EMR showed diagnoses including anoxic brain damage, schizoaffective disorder, history of falling, psychoactive substance abuse, hypertension, and dysphagia. R5's MDS dated [DATE], showed R5 had mild cognitive impairment and required maximal assistance from one staff for personal hygiene and was dependent on staff for toileting hygiene. R5's February 9, 2022, care plan showed a focus of frequent bladder and bowel incontinence, with interventions which included, I would like the staff to check me for incontinence episode every 2 hours and as needed. I would also need assistance to wash, rinse and dry my perineum. I would also need assistance to change clothing PRN (As Needed) after incontinence episodes.
Residents Affected - Some
4. On March 8, 2024, at 01:34 PM, V6 (CNA) assisted R6 with incontinence care. V6 assisted R6 to the bathroom and pulled his pants down. R6 had two pull-ups on. V6 pulled down R6's outer pull-up and then removed R6's inner pull-up. V6 then pulled up the outer pull-up and his pants. V6 said she last changed R6 in the morning and she normally changed R6 twice a day. The EMR showed diagnoses including alzheimer's disease, type 2 diabetes mellitus, dementia, depressive disorder, and unspecified symptoms and signs involving cognitive functions and awareness. R6's MDS dated [DATE], showed R6 had severe cognitive impairment and required supervision for personal hygiene and setup or clean up assistance for toileting hygiene. On March 8, 2024, at 1:50 PM, V9 (LPN/Licensed Practical Nurse) stated the staff should not be putting two briefs on the residents, just one. On March 8, 2024, at 1:53 PM, V10 (LPN) stated the CNAs know they should not be putting two incontinence briefs on the residents. On March 8, 2024, at 1:58 PM, V11 (CNA) stated the residents should only have one incontinence brief on. V11 stated it did not make a difference to put double briefs on because the resident was still wet. On March 8, 2024, at 2:01 PM, V12 (CNA) stated the CNAs should never put two briefs on the residents and she only applied one brief. On March 8, 2024, at 3:27 PM, V2 (DON/Director of Nursing) said the CNAs should be putting only one brief on the resident. V2 stated it was not appropriate to say the resident was a heavy wetter as rationale for putting two briefs on. V2 stated she re-educated the staff about frequent toileting and rounding every two hours. V2 said even if the resident requested two incontinence briefs, the staff were supposed to educate the resident and the CNA should report the request to the nurse on duty. The facility's July 28, 2022, Incontinent and Perineal Care policy showed Do rounds at least every 2 hours to check for incontinence during shift. The facility's July 28, 2023, General Care policy showed It is the facility's policy to provide care for every resident to meet their needs.
145339
Page 2 of 2
