Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, post-traumatic seizures, insomnia, anxiety disorder, essential tremor, and a history of traumatic brain injury was observed to have visibly wet pants for an extended period while sitting in a common area. The resident's Minimum Data Set indicated that he was rarely or never understood and was dependent on staff for toileting hygiene. The care plan noted a risk for impaired skin integrity and a history of refusing incontinence care at times. On the day in question, the resident was first observed with visibly wet pants at 9:15 AM, and this condition persisted until at least 11:50 AM. Multiple staff members, including CNAs, the Activities Assistant, the DON, and the CNA Supervisor, walked by or interacted with the resident during this time but did not address or acknowledge the resident's soiled condition. Some staff asked the resident if he wanted to use the bathroom or take a shower, but the resident either declined or did not respond. Staff interviews later revealed that the resident sometimes refused care, but alternative approaches, such as having a different staff member ask, were not consistently attempted during the observed period. Despite the facility's expectation that residents should be checked for incontinence at least every two hours, there was no documented policy on this practice, and the resident remained in soiled clothing for several hours. When the resident was finally assisted to the shower room, redness was observed on his buttocks and groin. The failure to provide timely incontinence care and maintain the resident's dignity was directly observed and confirmed through staff interviews and record review.