Failure to Provide Timely Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A resident with diagnoses including mixed/urinary incontinence, a vulvar malignancy, obesity, and a radiation-induced groin wound was identified as fully dependent on staff for toileting and incontinence care. The resident was assessed as cognitively intact and had a care plan indicating a self-care deficit in bed mobility, requiring staff assistance for repositioning and hygiene. The care plan also noted the resident was at risk for abuse and neglect. According to interviews and documentation, the resident was left soiled in feces for several hours during the night, despite using the call light and contacting family for help. The resident reported feeling exposed, uncomfortable, and emotionally distressed, and was not provided incontinence care until police arrived for a well-being check. Family members corroborated the resident's account, stating they received multiple distress calls from the resident throughout the night, attempted to contact the facility without success, and ultimately called the police. The police report confirmed the resident was found lying in bed without undergarments, with a significant amount of feces present, and a strong odor in the room. Police observed that staff were slow to respond to the resident's needs, and one staff member attempted to attribute the lack of care to alleged behavioral issues, which was contradicted by social services and the care plan, both of which indicated no such behaviors were present. Staff interviews revealed significant staffing shortages on the night in question, with only one nurse and one CNA present when two nurses and four CNAs were required for the unit. The nurse on duty reported being unable to provide care to the resident due to the lack of available assistance, and another CNA stated that care was provided but did not document it, while another CNA denied being assigned to the resident. The administrator acknowledged that failure to provide incontinence care as required constitutes neglect, and the facility's abuse policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress.