Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with a history of acute on chronic systolic congestive heart failure and major depressive disorder, who was cognitively intact but dependent on staff for activities of daily living (ADLs) including toileting, did not receive timely incontinence care. The resident experienced a decline in condition after a hospitalization, resulting in increased dependence for ADL care. On the evening in question, the resident was left in a soiled brief and saturated bed sheets for at least 10 hours, with urine soaking through to the mattress. Observations and interviews confirmed that the resident requested assistance to use the bathroom but was told by a CNA to remain in bed for the staff's convenience, and was not provided with incontinence care in a timely manner. Staff interviews and record reviews corroborated that the resident was found in the morning with soiled linens and a soaked brief, and that the resident had redness to her buttocks. The facility's own policy required appropriate support and assistance with ADLs for residents unable to perform them independently, but this was not followed. The incident was documented through direct observation, staff and responsible party interviews, and review of video evidence, all indicating a failure to provide necessary services to maintain the resident's hygiene and dignity.