Resident Left Without Timely Bed Transfer and Incontinence Care
Penalty
Summary
A resident with morbid obesity, lymphedema, major depressive disorder, generalized anxiety disorder, muscle weakness, and an acquired absence of the right leg below the knee, who was cognitively intact but dependent on staff for transfers and toileting, was not assisted to bed or provided timely incontinence care during a night shift. The resident reported using the call light multiple times and was told by an aide that assistance was delayed due to the need for a second aide for a mechanical lift transfer. The aide later informed the resident that the other aide was on break and he would have to wait. After having a bowel movement, the resident was again told he would have to wait, but no one returned to assist him, and he remained in his wheelchair until the morning shift arrived. Upon arrival of the day shift, staff found the resident still in his wheelchair, soiled, and with a full urinal and cups of urine. The resident expressed that the experience was demeaning and that his requests for care and to go to bed were not honored. Staff interviews confirmed that the resident had been left up all night and that the night shift was short-staffed, with one aide unaccounted for during much of the shift. The incident was not documented in the resident's progress notes, and there was no record of the resident being left in his wheelchair or not receiving incontinence care throughout the night. Further interviews with staff and management revealed inconsistent accounts regarding whether the resident was put to bed as requested. Some staff stated the resident was left in his chair all night, while others claimed he was put to bed. The agency aide assigned to the resident was reported to have left her duties and was subsequently placed on a do-not-return list. The facility's policy states that residents have the right to choose their daily routines, including sleeping and waking times, and to receive care consistent with their needs and preferences. However, in this instance, the resident's autonomy and dignity were not respected, and his care needs were not met in a timely or respectful manner.