Resident Left in Soiled Brief for Extended Period Due to Delayed Staff Response
Penalty
Summary
A resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness, was left in a soiled brief for an extended period of time. The resident's call light was observed ringing at approximately 9:05 PM, and he was heard calling out for assistance multiple times without receiving a response. During this period, staff including an LPN and multiple nurse aides were present in the hallway but did not respond to the resident's needs. The LPN eventually entered the resident's room at 9:25 PM, acknowledged the request for assistance, and informed the resident that she would notify the appropriate aide. However, the resident's call light was turned off without care being provided at that time. Subsequent interactions among staff indicated a lack of immediate response, as the aides either did not address the resident or prioritized other tasks. The resident ultimately received care at approximately 9:45 PM, resulting in a wait time of about 40 to 45 minutes while remaining in a soiled brief. During an interview, the resident expressed awareness of staffing challenges but described the experience as undignified and distressing. The facility census at the time was 111.