Failure to Provide Prompt Incontinence Care and Maintain Resident Dignity
Penalty
Summary
Staff failed to provide prompt incontinence care to a resident who was dependent on staff for all toileting needs and was always incontinent of bowel. The resident, who had a history of depression, bipolar disorder, paraplegia, and recent Clostridioides difficile infection, experienced a bowel movement as he was assisted out of his room, which was then closed for pest control spraying. Staff were aware the resident was soiled but did not know how to proceed since his room was unavailable and there were no empty rooms on the unit. The resident remained in the common area, sitting in feces for approximately an hour, while staff expressed uncertainty about where to provide care and did not immediately seek guidance from supervisors. Observations confirmed the resident remained soiled in the common area until staff were eventually directed to return him to his room after it was deemed safe. Upon being assisted to his room and transferred to bed, the resident was found to have feces on and between his buttocks, extending from his scrotum to a bandage on his sacral/coccyx area. Interviews with staff and management indicated that incontinence care should have been provided immediately and that alternative arrangements, such as using an empty room or therapy room, were expected when the resident's room was unavailable. Facility policy also required prompt response to toileting needs to maintain resident dignity.