Failure to Provide Timely Incontinent Care Resulting in Neglect
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting hygiene and incontinent care was not provided timely assistance. The resident, who was cognitively intact and at risk for skin breakdown, requested incontinent care from a CNA during the night shift. The CNA checked the resident with a flashlight, stated that the resident was fine, and did not provide the requested care. The resident remained soiled with dried bowel movement from the back down to the ankles until the next shift, when two other CNAs discovered the situation and provided care. Documentation showed a significant gap between the last recorded incontinent care and the next, spanning several hours overnight. Further review revealed that the resident's skin was red and raw, requiring the application of a zinc barrier cream. Facility records and interviews indicated that this was not an isolated incident, as multiple CNAs reported delays in providing timely care, and several grievances had been filed regarding long wait times for assistance. The facility's own policy defined neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which was not adhered to in this case.