Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence by not providing timely perineal care after episodes of incontinence. Clinical record review showed that a resident with hemiplegia, anxiety, and depression was frequently incontinent and dependent on staff for toileting hygiene. The resident was found on multiple occasions in saturated briefs and bedding, with staff documentation indicating that the resident remained in soiled conditions for extended periods. Staff interviews confirmed that this was not an isolated incident, as several staff members reported that residents assigned to a particular CNA were often left wet and required complete bed changes at shift change. Multiple staff, including CNAs, an RN, and an LPN, reported ongoing issues with the same CNA failing to complete rounds and change residents as required, resulting in residents being left in soiled briefs and bedding. Staff described finding residents with dark, wet briefs and bed pads with urine rings, and noted that rooms had persistent odors. Staff also reported that grievances had been filed regarding this CNA's conduct, and that the issue had persisted for over a year, with some staff escalating concerns to charge nurses and the DON. Despite these reports and grievances, facility leadership, including the Administrator and DON, were either unaware of recent grievances or had not followed up on them. Documentation of follow-up to grievances was lacking, and there was no evidence that audits or investigations were consistently conducted in response to staff concerns. The facility's own policy required prompt response to toileting needs and care that promoted dignity, but this was not consistently provided to the resident in question or to other residents affected by the same staff member.