Federal inspectors found the incontinence care violations during a May 2024 survey at Complete Care at Brick LLC, where staff routinely layered multiple adult briefs on residents to extend time between changes. The practice violated facility policy and risked serious skin breakdown for vulnerable residents.
When surveyor accompanied a nursing assistant into one resident's room at 9:23 AM on May 20, they discovered the resident wearing two briefs. The inner brief was soiled, but hadn't soaked through to the outer brief or the absorbent pads beneath the resident.
"Either the resident was a heavy wetter or they were short staffed," the nursing assistant explained when asked why the resident wore two briefs.
The aide revealed that another day shift worker had instructed her to "double brief" residents. She said she had also put two briefs on two other residents that morning after receiving the same instruction.
When inspectors checked a second resident at 9:36 AM, they found three briefs layered on the person. The nursing assistant said the resident had wet through the first brief, but the two outer briefs remained dry. However, the absorbent pad directly beneath the resident was soaked through with urine.
"The resident was not properly cared for or changed every two hours," the aide admitted when asked how the outer briefs could be dry while the padding underneath was saturated.
A third resident wore two different-sized briefs when inspectors arrived at 9:44 AM. The resident told surveyors they had last been changed at 5:00 AM and wouldn't normally be changed again until 10:30 AM.
The unit manager who accompanied inspectors during the observations expressed shock at the findings.
"This should not be," she said after discovering the multiple briefs and soaked padding. She explained that staff weren't allowed to double brief because it could cause skin breakdown.
The manager said either staff didn't want to change residents frequently or mistakenly thought some residents were "heavy wetters," neither of which justified the practice.
All three residents had care plans specifically addressing their incontinence and skin breakdown risks. Resident #23's plan called for cleaning the peri-area with each incontinence episode and encouraging fluids to promote voiding responses. Resident #30's plan required frequent position changes and avoiding prolonged positioning on the tailbone area.
The unit census that morning was 42 residents with six aides and three nurses. The night shift had operated with just three aides for all 42 residents, creating a ratio of 14 residents per aide.
"It did not seem that the residents were checked every two hours," the unit manager told inspectors, adding that she was surprised by what they found.
A licensed practical nurse assigned to the three residents confirmed that residents should be checked every two hours if staffing ratios were adequate. She said double briefing wasn't proper and would lead to skin breakdown.
"The aides may have done that to minimize the frequency of changes," she explained.
Another nursing assistant told inspectors that using multiple briefs, liners, and absorbent pads prevented residents' skin from breathing and could cause breakdown. She said some agency aides used the double briefing technique, but long-term staff should know better.
The Director of Nursing, who started working at the facility in October 2023, called the practice unacceptable for multiple reasons including dignity concerns. She said there was no reason to double brief residents, and those on diuretics should be changed more frequently, not given extra briefs.
"It was poor practice to double brief and she hoped that it was not the standard at the facility," inspectors noted.
The administrator said if double or triple briefing was discovered, he would check with both staff and residents to determine if it represented a resident preference. He said if an aide was responsible, "severe education was done."
Beyond the incontinence care failures, inspectors documented additional staffing-related problems. They found a feeding tube pump running while disconnected from a resident, causing nutritional formula to drip onto the floor. The same resident's equipment hadn't been properly maintained, with dried formula residue coating the pump's pole and an irrigation syringe that should have been replaced daily still in use after two days.
An air mattress designed to prevent pressure sores was set to 280 pounds for a resident who weighed only 85 pounds, potentially impeding wound healing for someone with a Stage IV pressure ulcer.
The facility had developed policies prohibiting double briefing after the inspection. An undated staff training document stated: "Double diapering is not allowed, resident's are to be rounded and checked on every 2 (two) hours or as needed, double diapering can be uncomfortable to the resident and can potentially cause skin impairment."
One resident with a facility-acquired pressure ulcer never had an incident report completed to investigate how the wound developed, despite facility policy requiring prompt investigation of all injuries and incidents.
The violations affected residents across multiple units, with inspectors finding evidence that staffing shortages compromised basic care standards throughout the facility. The nursing assistant who discovered residents in soaked padding and multiple briefs continued her rounds that morning, still having four more incontinent residents left to change.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Brick LLC from 2024-06-06 including all violations, facility responses, and corrective action plans.