Failure to Provide and Document Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from neglect by not ensuring that incontinence care was provided according to the resident's needs. The resident, who had diagnoses including dementia, Parkinson's disease, and overactive bladder, was assessed as frequently incontinent and required partial to moderate assistance for toileting and hygiene. Despite being care planned for urinary incontinence and having urinals at the bedside, the resident reported that call lights were used throughout the night without response, resulting in a full urinal and wet bed and clothing in the morning. Multiple staff interviews confirmed that the resident was found in this condition at shift change, and the resident expressed dissatisfaction with the care received during the night shift. The facility's investigation into the incident revealed conflicting staff accounts regarding the care provided during the night in question. While some staff stated that the resident was attended to multiple times, there was no documentation in the clinical record to support that incontinence care was provided or that the resident refused care during the relevant shift. The lack of documentation extended to several other days and shifts, as verified by the Director of Nursing, indicating a broader issue with record-keeping for incontinence care and resident refusals. The facility's policies required identification and intervention in situations where neglect could occur, but the absence of documentation made it impossible to verify that the resident's needs were met. The investigation ultimately verified the allegation of neglect due to the inability to disprove the resident's claim and the lack of evidence showing that appropriate care was provided during the night shift.