Resident Left Unattended in Urine Due to Delayed Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with moderate intellectual disability and anxiety disorder, who was assessed as continent of bowel and bladder but requiring cues to use the toilet, was found sitting in urine in a dining room chair. The incident took place in the evening, after the resident had been assisted to the dining room for her meal and had not been attended to for an extended period. Family members discovered the resident in this condition, with a puddle of urine on the floor and a wet brief around her ankle, and reported their concerns to staff present in the room. The male RN on duty at the time was present in the dining room, working on a computer, but did not notice or address the resident's condition until the family brought it to his attention. The CNA assigned to the resident stated she had last changed the resident before dinner and had not checked on her again until after the family reported the incident. The CNA explained that her routine was to perform check and change room by room after dinner, and the dining room was at the end of her route, which contributed to the delay in care. The facility's policy requires that residents unable to perform activities of daily living independently receive necessary assistance with hygiene and toileting. Despite this, the resident was left unattended and wet for an undetermined period, contrary to the facility's expectations and policy. The DON confirmed that staff are expected to immediately address such situations, especially when not engaged in direct resident care.