Resident Left in Soiled Diaper for Over Five Hours, Dignity Not Maintained
Penalty
Summary
A resident with a history of a left tibia fracture, COPD, diabetes mellitus, and schizophrenia, who was cognitively intact but required maximum assistance for activities of daily living, was left in a soiled diaper for over five hours. The resident was observed to be awake, fidgeting, and visibly uncomfortable, and expressed frustration about not being changed. Despite the resident's request for assistance, a CNA informed the resident that she would notify the assigned CNA but did not provide care herself. Another CNA later stated she was too busy with other residents to assist, acknowledging that the resident was not provided dignity or able to exercise her rights. Facility policy required that residents wait no longer than two minutes to be changed and emphasized treating residents with dignity, respect, and kindness at all times. The failure to provide timely incontinence care resulted in the resident feeling upset and undignified, directly contravening the facility's stated policies and procedures regarding resident rights and dignity.