Failure to Provide Dignified and Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to address a resident's need for incontinence assistance in a respectful and dignified manner. The resident, who had intact cognition and multiple diagnoses including cancer, anemia, hypertension, diabetes, psychotic disorder, and COPD, was always incontinent of bowel and bladder and required extensive assistance for toileting and total assistance for transfers using a full body mechanical lift. The resident's care plan directed staff to check and change her and/or offer a bed pan at specific times and as needed, but documentation showed the bowel toileting program was inconsistently followed, with the program only implemented one day during a reference week. On the day of the observed incident, the resident requested assistance after an incontinence episode following breakfast. Multiple staff entered and exited the room, assisting the roommate and performing other tasks, but did not promptly address the resident's request for incontinence care. The resident waited for an extended period, expressing discomfort and distress about her situation. Staff interviews confirmed that the resident required assistance of two for transfers and that she did not like using the bed pan due to discomfort. Although the use of a commode had been discussed, it had not been trialed, and staff were not fully aware of the resident's preferences or continence needs. Interviews with nursing staff and administration revealed a lack of awareness regarding the resident's toileting preferences and the implementation of her care plan. Staff responses indicated that assistance was provided after other tasks were completed, and there was no clear communication or prioritization to meet the resident's needs in a timely manner. The facility's policy required residents to be treated with respect and dignity, but the observed delay and lack of individualized care did not align with these expectations.