Failure to Safeguard Resident Belongings and Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to respect and safeguard the personal belongings of a resident with a history of intracranial injury. The resident's family reported that a personally purchased and labeled transfer sling had been missing for over two months, and a wheelchair, also labeled, had previously gone missing but was later found in another unit. Additionally, a pair of black orthopedic shoes intended to prevent foot deformities was lost for about three months, requiring the family to purchase a replacement. Despite the family providing receipts for reimbursement, there was no documentation that reimbursement occurred, and the family expressed emotional distress and frustration over the repeated loss and mishandling of the resident's belongings. Another deficiency involved the failure to treat a resident with respect and dignity during incontinence care. A resident with chronic kidney disease, heart failure, and incontinence, who was cognitively intact and dependent on staff for personal care, reported that a CNA placed two rolled towels inside their disposable brief. The resident and their representative both stated this caused significant emotional distress. Upon investigation, another CNA confirmed finding the wet towels during a shift change after the resident complained of discomfort. The CNA responsible admitted to placing towels and sometimes paper towels in the resident's brief in an attempt to keep the resident dry, as the resident frequently requested to be kept dry. The care plan for the resident indicated a risk for incontinence-associated dermatitis and directed staff to provide perineal care and regular toileting, but did not include the use of towels or other absorbent materials inside briefs. The unit manager confirmed that such practices were inappropriate and not permitted.