Delay in Incontinence Care and Transfer Assistance Leads to Resident Distress
Penalty
Summary
A resident who required staff assistance for activities of daily living (ADLs), including incontinence care and transfers, was left waiting for over an hour without timely help. The resident was observed sitting on the side of the bed with a walker in front, unable to reach the call light, which was wrapped around the bedside table behind him. Urine was present on the floor beneath the resident, with his foot in the puddle, and he reported waiting for assistance to be cleaned and transferred to a chair. The resident expressed feelings of humiliation and embarrassment due to the prolonged wait and lack of care. The resident's medical record indicated a need for assistance with personal care, muscle weakness, abnormal gait, unsteadiness, and a history of falls, but he was cognitively intact. Staff interviews revealed that the CNA assigned to the resident had a heavy workload and was unable to provide timely assistance due to staffing shortages and the need for two-person assistance for safe transfers. The CNA stated that only one nurse and one other CNA were working on the unit, making it difficult to provide prompt care. The Assistant DON confirmed that any staff member could assist residents and that waiting an hour for help was excessive. Facility policies required that residents unable to perform ADLs independently receive appropriate care and that call lights be within easy reach, both of which were not followed in this instance.