Failure to Provide Timely Incontinence Care and Adequate Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide timely and professional incontinence care, as well as adequate bathing for dependent residents. In one instance, a resident who returned from therapy after a bowel movement waited 57 minutes before receiving incontinence care, despite multiple staff being informed of the need. Staff interviews revealed that coverage during breaks was inconsistent, leading to extended wait times for residents requiring assistance. Additionally, documentation showed that another resident was not bathed according to their scheduled shower days during their short stay, and a review of another dependent resident's records indicated they received only one shower in a month without any documentation of refusal. Staff confirmed that only one of two shower rooms in a unit was functional, with the other out of order for several months, resulting in only four working showers for 130 residents. Furthermore, a resident was left in a hallway from 4 AM to 12 Noon after being moved out of bed for linen changes following an incontinence episode. Interviews with family and anonymous sources confirmed that the resident called out for help throughout the night and was left unattended in the hallway for several hours. These findings were based on observations, record reviews, and staff and family interviews, demonstrating a pattern of delayed and inadequate care for residents dependent on staff for activities of daily living.