Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
A deficiency occurred when a resident with bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care. The resident reported needing to be changed before daylight and had requested assistance from the overnight nurse aide, who acknowledged the request but did not return to provide care. The resident remained in soiled briefs into the morning, resulting in a strong odor in the room. When the day shift arrived, the resident was given a breakfast tray but declined to eat until he was cleaned, stating he could not eat in that condition. The nurse aides on the morning shift indicated they could not provide incontinence care while meal trays were being passed and believed the overnight shift should have ensured the resident was clean before breakfast. Staff interviews confirmed that it was expected for residents to be clean and dry before breakfast, and the DON stated it was unacceptable for residents to be left in soiled briefs while being served meals. The resident expressed ongoing dissatisfaction with this pattern of care since admission, feeling neglected and undignified. The failure to provide timely incontinence care resulted in the resident being left in an unclean state during mealtime, directly impacting his dignity and comfort.