Health inspection·April 5, 2023

§483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2) For a resident with urinary incontinence, based on the resident’s comprehensive assessment, the facility must ensure that— i.A resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary. ii.A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary; and iii.A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident’s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. §72527. Patient Rights (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 72315 (b) Nursing Service – Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The California Department of Public Health (CDPH) received an anonymous complaint on 1/23/2023 regarding many resident care issues, including many call bells not within residents’ reach and several residents with skin not moisturized and protected from effects of incontinence. On 2/1/2023, CDPH conducted an unannounced onsite complaint investigation at the facility. The facility failed to: 1. Ensure the nursing staff assisted Resident 1, who was continent of bowel and bladder, and had a high risk for a pressure ulcer (an injury that breaks down the skin and underlying tissue) development, received care and services to maintain bowel and bladder continence timely to go to the bathroom to maintain the resident’s continence of bowel/bladder. 2. Ensure Resident 1 had access to the hallway bathroom or a bedside commode when she needed to urinate and/or have a bowel movement. 3. Implement Resident 1’s plan of care and the Interdisciplinary Team ([IDT] a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) assessment for the staff to assist Resident 1 with toileting to ensure the resident’s needs were met and the resident remained continent. 4. Ensure Resident 1’s dignity was maintained by not putting an adult brief (adult diapers designed to provide full incontinence protection) on the resident for staff’s convenience due to shortage of staff. As a result, Resident 1, who was continent of both bowel and bladder was being encouraged to use a diaper instead of using a bedside commode or being taken to the hallway bathroom outside the resident room to maintain the resident’s continence. Resident 1 expressed feelings of lack of dignity and being embarrassed of using a diaper. During an initial tour of the facility on 2/1/2023 at 5:20 a.m., there was two certified nurse assistants (CNAs 1 and CNA 2) and one licensed vocational nurse (LVN 1) on duty to care for 43 residents. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1, an 86-year-old female, was admitted to the facility on 10/19/2022 with diagnoses including neuropathy with ataxia (lose muscle control in the arms and legs), Type 2 diabetes mellitus (disease that occurs when blood glucose [sugar in the blood] was too high) and muscle weakness. During a review of Resident 1’s history and physical (H/P), dated 10/20/2022, the H/P indicated Resident 1 had the ability to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/18/2023, the MDS indicated Resident 1 could always understand and be understood by others. According to the MDS, Resident 1 was continent of bowel and bladder, required an extensive assistance (resident involved in activity, staff provide weight-bearing [body weight] support) with at least two-persons physical assistance during toilet use and transfers (how resident moves between surfaces such as bed, chair, wheelchair, standing position) between surfaces. The MDS indicated Resident 1 was at risk for developing pressure ulcers/injuries. During a review of Resident 1’s Care Plan (C/P), initiated on 1/18/2023, the C/P indicated Resident 1 was aware she could urinate and have a bowel movement in the diaper. The C/P goals indicated Resident 1 would remain continent of bowel and bladder through the next review date and at all times [sic]. The staff’s interventions included to assist the resident with toileting needs. During a review of Resident 1's IDT conference notes, dated 1/31/2023, the IDT notes indicated Resident 1 was at risk for skin breakdown due to resident needing extensive assist with bed mobility and transferring. The IDT notes indicated staff would assist the resident with bowel and bladder every two hours while awake. During an interview on 2/1/2023 at 5:45 a.m. with CNA 1, CNA 1 stated she, CNA 2 and one LVN were the only staff working on the night shift from 11 p.m. until 7 a.m. CNA 1 stated it was difficult to meet the toileting needs of the residents because many residents required a two-persons physical assistance and there were not enough staff at night to accommodate the residents’ toileting needs. CNA 1 stated Resident 1 can tell when she needs to urinate or have a bowel movement. CNA 1 stated the staff at night was not always able to assist Resident 1 to the bathroom in time as she needs a two-person physical assistance in getting her up into and from a wheelchair. CNA 1 stated Resident 1 agreed to wear a diaper to avoid sitting in a mess although Resident 1 has the capability of going and sitting on a toilet. During an observation on 2/1/2023 at 9:30 a.m., while in Resident 1’s room, Resident 1 was observed sitting up in bed eating breakfast. A wheelchair was at the resident’s bedside and there was no bathroom observed in the resident’s room. During an interview on 2/1/2023 at 9:35 a.m. with Resident 1, Resident 1 stated she does not have a bathroom in her room but there was a bathroom outside of her room in the hallway. Resident 1 stated when staff can assist her, she prefers to use the bathroom and not to wear a diaper. Resident 1 stated she does not need to wear a diaper, but the staff puts a diaper on her, especially at night because the staff cannot attend to her needs on time. Resident 1 stated she needs two people to help her into the wheelchair to get to the bathroom. Resident 1 stated, “I feel embarrassed to wear a diaper and it was not dignified but I guess it is better than sitting in a mess.” During an interview on 2/1/2023 at 2:20 p.m. with the MDS Coordinator, the MDS coordinator stated Resident 1 was continent of bowel and bladder and should be accommodated to get up to use the bathroom or use a bedside commode (a portable toilet). The MDS coordinator stated by not accommodating the resident’s needs Resident 1 was at risk for urinary tract infections ([UTI] an infection in any part of the urinary system), skin irritation, loosing continence of bowel and bladder and embarrassment. During an interview on 2/1/2023 at 4 p.m. with the Director of Nursing (DON), the DON stated the facility must accommodate the toileting needs of the residents and provide staff to assist residents to the bathroom. The DON stated by not assisting the resident in time to get to the bathroom, the resident will continue to urinate in her diaper and be at risk for UTIs and skin breakdown and can cause embarrassment for a resident, which does not enhance the resident’s dignity. During an interview with Resident 1 on 2/17/2023 at 8:40 a.m., Resident 1 stated, “I have not worn a diaper since I was a baby, and it makes me feel like a baby.” Resident 1 stated she was embarrassed, frustrated, and angry that she had to be wet in a diaper. Resident 1 stated she urinates in the diaper and have had one bowel movement (BM) in the diaper since she has been admitted to the facility (10/2022). Resident 1 stated sometimes when she calls for help to go to the bathroom, the staff brings a bedpan (a receptacle used by a bedridden resident as a toilet) which was very uncomfortable on her buttocks. Resident 1 stated she would rather use the bathroom rather than urinate or have a BM in a diaper because sitting on a toilet “feels more natural.”   During a review of the facility’s policy and procedure (P/P) dated 8/2022 and titled, “Urinary Continence and Incontinence-Assessment and Management,” the P/P indicated as part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. The P/P indicated relevant information related to urinary continence included functional and or cognitive or limitations that could affect continence, including impaired mobility, decreased upper and lower extremity muscle strength, additional information such as type of frequency of physical assistance necessary for the resident to access the toilet or commode and environmental factors that may restrict or facilitate resident’s access to the toilet, including distance to the toilet or commode. The P/P indicated the nursing staff and physician will identify risk factors for becoming incontinent including environmental factors (immobility and lack of toilet). The facility failed to: 1. Ensure the nursing staff assisted Resident 1, who was continent of bowel and bladder, and had a high risk for a pressure ulcer (an injury that breaks down the skin and underlying tissue) development, received care and services to maintain bowel and bladder continence timely to go to the bathroom to maintain the resident’s continence of bowel/bladder. 2. Ensure Resident 1 had access to the hallway bathroom or a bedside commode when she needed to urinate and/or have a bowel movement. 3. Implement Resident 1’s plan of care and the Interdisciplinary Team ([IDT] a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) assessment for the staff to assist the resident with toileting to ensure the resident’s needs were met and the resident remained continent. 4. Ensure Resident 1’s dignity was maintained by not putting an adult brief (adult diapers designed to provide full incontinence protection) on the resident for staff’s convenience due to shortage of staff. As a result, Resident 1, who was continent of both bowel and bladder was being encouraged to use a diaper instead of using a bedside commode or being taken to the hallway bathroom outside the resident room to maintain the resident’s continence. Resident 1 expressed feelings of lack of dignity and being embarrassed of using a diaper. These violations, jointly, separately or in any combination had a direct or immediate relationship to the health, safety, or security of Resident 1.