Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with paraplegia, stage 4 sacral pressure ulcer, third degree burns on both lower legs, clostridium difficile infection, neuropathic bladder, and chronic embolism/thrombosis of the right lower extremity was found to have been left in a soiled brief for an extended period overnight. The resident was totally dependent on staff for toileting hygiene and was always incontinent of bowel, requiring frequent checks and assistance. According to the resident, after experiencing severe diarrhea one night, she requested assistance to be changed around 9:45 PM, but was told by a CNA that the next shift would handle it. No staff attended to her until approximately 6:15 AM the following morning, when the wound care nurse found her still soiled, with stool present in her brief and on her sheets. Staff interviews confirmed that the resident was alert, oriented, and unable to feel if she was wet or soiled, necessitating regular incontinence checks. The wound care nurse corroborated the resident's account, noting the presence of stool and a strong odor in the room, as well as soiled sheets. The facility's policy required resident checks at least every two hours, especially for those who are bedbound and require assistance with turning and incontinence care. The Director of Nurses also stated that such checks are necessary to maintain resident dignity and prevent infection and skin breakdown.