Failure to Provide Timely Incontinence Care Resulting in Harm
Penalty
Summary
Facility staff failed to provide timely incontinence care to multiple residents who were dependent on staff for activities of daily living, resulting in psychosocial and physical harm. One resident with quadriplegia, who required total assistance, was observed to have his call light engaged for over 50 minutes before staff responded to his request for incontinence care. The resident reported routinely waiting extended periods for care, which led to feelings of anger, humiliation, and being unimportant. Clinical records indicated that this resident developed incontinence-associated dermatitis (IAD) on both buttocks, with wound care documentation confirming new skin breakdown attributed to delayed incontinence management. Another resident, who was dependent for toileting and had no cognitive impairment, reported being left in feces for approximately two hours after notifying staff of the need for a brief change. The resident described significant discomfort, burning, and emotional distress as a result of the delay. Observations and interviews confirmed that the resident's skin was red and irritated, and photographic evidence showed feces on the resident's thighs, bed pad, and sheets. Staff interviews corroborated the delay, and the resident reported the incident to multiple facility leaders, who were unaware of the situation until informed by surveyors. A third resident, with severe cognitive impairment and a history of urinary tract infection, was found to have remained in the same brief for eight hours, as confirmed by staff interviews and photographic evidence provided by the resident's daughter. The resident's brief was saturated, and skin assessments documented redness and moisture-associated skin damage to the coccyx and groin areas. Staff interviews revealed inconsistent practices regarding the frequency of incontinence care and reliance on visual indicators rather than direct assessment, contributing to prolonged exposure to moisture and subsequent skin breakdown.