Failure to Provide Timely Incontinent Care and Protection from Neglect
Penalty
Summary
The facility failed to protect two residents from neglect related to activities of daily living (ADLs), specifically in the provision of incontinent care and personal hygiene. One resident, who was dependent on staff for bathing and toileting due to advanced dementia and anxiety disorder, was left in a soiled brief for approximately two hours. This incident was reported by the resident's roommate, who stated that she repeatedly asked the assigned CNA to change the soiled brief, but the CNA refused, claiming the resident was not dirty. The roommate eventually used the call light, but the CNA did not return for over an hour, resulting in the resident remaining in a soiled state for an extended period. The care plan for this resident required frequent checks and prompt cleaning after incontinence episodes, which was not followed. Another resident, with diagnoses including anxiety disorder, functional quadriplegia, and a chronic skin condition causing painful sores on the legs, was left without completed incontinent care when the same CNA left the room before finishing. The resident was left with an untaped, soiled brief and uncovered, causing distress. When the CNA returned, the resident requested that her legs not be touched due to pain and dressings, but the CNA slapped or tapped her right leg with an open hand, causing pain and emotional upset. The incident was witnessed and corroborated by an occupational therapist, who also reported the event to facility leadership. Both incidents were confirmed through interviews with staff, residents, and review of facility records. The facility's policies required prompt and thorough incontinent care, as well as measures to prevent neglect and ensure residents' well-being. In both cases, the assigned CNA failed to follow these policies, resulting in residents not being well-groomed and experiencing unnecessary pain and psychosocial distress.