Failure to Provide Timely Incontinence Care and Call Bell Response Resulting in Neglect and Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care and respond to call bells for multiple residents, resulting in neglect, skin injury, and psychosocial harm. One resident, who was cognitively intact and completely dependent on staff for all activities of daily living due to quadriplegia, was left sitting in feces for over fifty minutes after activating the call light. The resident reported feeling humiliated and unimportant, and was observed to be emotionally distressed. The resident's care plan indicated a high risk for pressure ulcers and required prompt incontinence care, but staff did not respond in a timely manner, and the call bell system showed the call had been active for over fifty minutes before staff entered the room. Another resident, who was dependent on staff for toileting and had no cognitive impairment, reported being left in feces for approximately two hours. The resident described that after activating the call bell and informing a CNA of the need for incontinence care, the CNA turned off the call light and did not return. The resident was eventually assisted by another CNA, who found fecal material on the resident's thighs, bed pad, and sheets, and observed significant skin redness and burning. The resident reported the incident to staff and Adult Protective Services, and photos documented the extent of the soiling and skin injury. A third resident, with severe cognitive impairment and dependent on staff for care, was found by a family member in a saturated brief and wet bedding. The family member marked the brief and found it unchanged eight hours later. Staff interviews confirmed that incontinence rounds were expected every two hours, but the resident's brief was not changed as required, resulting in moisture-associated skin damage. Staff acknowledged that the resident was wet enough to require a change, and documentation showed redness and treatment for skin damage following the incident.