Failure to Ensure Timely Incontinence Care and Resident Dignity
Penalty
Summary
The facility failed to promote resident dignity by not ensuring timely incontinence care for two residents who were cognitively intact and dependent on staff for toileting. One resident, with diagnoses including chronic respiratory failure, epilepsy, and major depressive disorder, reported having to wait long periods at night to be changed after episodes of incontinence. She described being left in soaked linens until morning, which caused her frustration, anger, and humiliation. Observations confirmed her brief was wet during care, and her roommate corroborated that staff often delayed responding to call lights, sometimes turning them off and not returning promptly. The Director of Nursing acknowledged that the resident's bed was often soaked, attributing it to her medications, and stated that staff were expected to check every two hours. Another resident, with bilateral lower limb amputations and major depression, also required assistance with toileting and reported waiting up to two hours for help after activating her call light, particularly in the evenings. She described having to sit in urine for extended periods, leading to feelings of disgust and humiliation. Her room was noted to have a urine odor, and she stated that her room was not cleaned on weekends, contributing to the persistent smell. Facility policy indicated residents have the right to be treated with consideration, respect, and full recognition of their dignity.