Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
Staff failed to provide incontinence care to two residents as requested prior to meal service, resulting in a lack of dignity and respect for their needs. Both residents had intact cognition and were dependent on staff for toileting due to mobility impairments and incontinence. The facility's policy required staff to check and provide incontinence care after each episode, but this was not followed in these instances. For one resident, the call light was activated to request a change before lunch. A staff member entered, turned off the call light, and stated help would be provided, but no care was given. The resident's request was relayed to the nurse and CNA, but the CNA did not provide care, stating that incontinence care was not performed during meal service. The resident remained unchanged through lunch, despite multiple staff being aware of the request. The second resident also requested to be changed before being brought to the dining area. The CNA acknowledged hearing the request but did not address it, instead bringing the resident to the dining table without providing care. Staff interviews confirmed that it was common practice not to provide incontinence care during meal times, citing infection control concerns. Both residents expressed a preference not to attend meals without being changed, and staff acknowledged that they would not want to be in a similar situation themselves.