Failure to Provide Timely Incontinence Care and Inadequate Investigation of Neglect Allegation
Penalty
Summary
Facility staff failed to provide timely incontinence care to a resident with multiple medical conditions, including heart failure, atrial fibrillation, and chronic incontinence. The resident, who was always incontinent of bowel and bladder, requested assistance from a CNA after a bowel movement but was told to wait due to staffing shortages. The resident waited for several hours before receiving assistance, during which time she blocked the CNA from leaving her room in an attempt to get help. Interviews revealed that the CNA felt unable to assist the resident promptly because she needed to attend to other residents and the nurse assigned to the area was on break. The resident eventually received incontinence care from an LPN and another CNA several hours after her initial request. The incident was reported to the ADON and DON, but neither conducted a thorough investigation or collected statements from involved staff or the resident. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress. The policy requires all allegations of neglect to be thoroughly investigated and reported. In this case, the facility did not follow its own policy, as the incident was not properly investigated or documented, and the resident's care needs were not met in a timely manner.