Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, dysphagia, and anxiety disorder was dependent on staff for all activities of daily living, including toileting and personal hygiene. The resident was always incontinent of bowel and bladder and had a care plan in place requiring staff to provide incontinence care every two hours and as needed, as well as to respond promptly when the resident was found to be incontinent. The resident also required cueing and set-up assistance during meals and was at risk for nutritional impairment. On the morning of the incident, the resident was observed in the dining room with urine-soaked pants extending down to the knees after breakfast. The resident approached staff, repeatedly stating he was sticky and needed help, but was asked to sit and wait next to the nurses' cart. Multiple staff members walked past as the resident continued to call out for assistance and stood up several times while waiting. It was not until ten minutes later that the resident was finally escorted to his room for care. Interviews with staff confirmed that incontinence care should have been provided immediately to maintain dignity and prevent discomfort, in accordance with the facility's dignity policy.