Failure to Ensure Dignified Care and Timely Incontinence Assistance
Penalty
Summary
The facility failed to maintain a dignified quality of life for a resident with multiple medical conditions, including diarrhea, legal blindness, physical debility, and depression. The resident was dependent on staff for toileting hygiene and transfers, and her care plan required that the call light and personal items be kept within easy reach, with prompt responses to requests for assistance. On the day of the incident, the resident's room had a strong foul odor, and the call light was found out of her reach, behind her wheelchair and under the bed covers. The resident, who is partially blind and unable to move her wheelchair independently, reported that she had been searching for the call light because she needed to be changed after a bowel movement that occurred shortly after breakfast. She stated she had been sitting in soiled briefs for an extended period, resulting in significant discomfort and pain, with the soiling spreading to her perineal area, stomach, and back. When staff were alerted, they confirmed the call light was not accessible and apologized, stating they would return with the necessary equipment to assist the resident. During the cleaning process, the resident exhibited pain, and her skin was observed to be very dark red. Staff acknowledged that if the call light had been within reach, the resident would have used it promptly, as she typically does not like to remain in soiled briefs. The staff also confirmed that call lights should always be within reach and that resident needs should be addressed promptly. The failure to provide the resident with access to her call light and timely incontinence care resulted in prolonged discomfort and compromised her dignity.