Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
Multiple residents who were dependent on staff for activities of daily living (ADLs), including toileting and hygiene, were left soiled, wet, and unchanged for extended periods. For example, one resident, who was cognitively intact and required substantial to maximal assistance for personal care, reported being left in urine and feces for 35-40 minutes after a CNA failed to respond to her request for help. This was corroborated by the resident's roommate and another CNA, who confirmed the resident and her linens were soiled and that the resident felt uncared for. Another resident stated that her call light was not answered in a timely manner and that she was not changed from morning until mid-afternoon, resulting in her bed being wet from incontinence. This resident, also cognitively intact and dependent for ADLs, expressed feeling terrible and dehumanized by the experience. A third resident reported being left wet and soiled in urine for an entire day shift, and recalled a previous incident of being left in stool. This resident also indicated that call lights were not answered and that staff and administration did not follow up after being informed of the issue. A registered nurse confirmed seeing soiled sheets and stated that CNAs are expected to check and clean residents before shift changes. A fourth resident, who was nonverbal and dependent for ADLs, was reported via an anonymous complaint to have not received care for an entire day, as witnessed by his roommate. Staff interviews revealed that all staff are responsible for answering call lights and that residents should not wait more than ten minutes to be changed. Facility policies reviewed emphasized the importance of timely response to call lights, maintaining resident dignity, and providing care that promotes well-being and self-worth. Despite these policies, the documented events show that residents were left soiled and unattended, with their needs for hygiene and dignity unmet.