Failure to Provide Required Incontinent Care and Neglect of Dependent Residents
Penalty
Summary
Two residents who were dependent on staff for toileting and personal hygiene did not receive the required incontinent care during an overnight shift. Both residents had care plans directing staff to provide incontinent care every two hours and as needed, to keep them clean and dry, and to ensure the call bell was within reach. Documentation and interviews revealed that a nurse aide failed to provide this care from the evening through the following morning, with no evidence of toileting hygiene being performed during the overnight hours. One resident, with diagnoses including peripheral neuropathy and morbid obesity, reported that after being put to bed in the evening, no staff entered the room to provide care or assist with toileting, and the call bell was not accessible. The resident was found soaked in the morning by the day shift staff. The other resident, with osteoarthritis and a history of recurrent urinary tract infections, similarly reported not receiving any care after a certain time in the evening, and that the nurse aide refused to assist with repositioning in bed, instructing the resident to do it independently despite their dependency. Facility documentation, including nurse notes and incident reports, corroborated the residents' accounts, and point of care records lacked evidence of overnight care being provided. The facility's policies require prevention of neglect and the provision of care as outlined in residents' care plans, but these were not followed during the incident in question.