Failure to Provide Timely Incontinence Care and Call Bell Response
Penalty
Summary
Facility staff failed to provide timely and adequate assistance with activities of daily living, specifically incontinence care, for residents dependent on staff. Multiple residents reported excessive wait times for call bell responses, with some waiting over an hour or even up to two hours for assistance. Residents described instances where staff turned off call bells without providing help or stated they would return but did not. Observations confirmed that staff, including nursing assistants, were seen using personal cell phones at the nursing station instead of attending to resident needs. Resident council meeting minutes documented ongoing concerns about delayed call bell responses, staff inattentiveness, and the use of personal devices during shifts, particularly on the second and third shifts. Clinical record reviews for two residents revealed care plans requiring regular toileting assistance and incontinence care due to conditions such as dementia, urge incontinence, impaired mobility, and a history of falls. Despite these documented needs, observations and interviews showed that residents were left in soiled briefs for extended periods, sometimes overnight, and were not assisted in a timely manner. One resident reported being left in a soiled brief for three hours overnight, while another had to wait for over 20 minutes for help and sometimes attempted to manage toileting independently despite mobility challenges. These failures were observed and corroborated by both residents and facility leadership, with the expectation for call bells to be answered within 10 to 20 minutes not being met.