Failure to Promote Dignity Due to Delayed Response to Toileting Assistance
Penalty
Summary
The facility failed to promote dignity for two residents who required assistance with toileting, as staff did not respond in a timely manner to their requests for help with toileting and hygiene. One resident, who had intact cognition, a history of urinary catheter use, bowel incontinence, and was fully dependent on staff for transfers, experienced significant delays in call light response, with logs showing response times ranging from 15 to 77 minutes. The resident's care plan required prompt response to all requests for assistance, but interviews and documentation revealed that the resident often waited extended periods, resulting in sitting in urine and feces, which caused distress and feelings of lost dignity. Family members and the resident reported long waits and expressed concerns about safety and emotional well-being due to these delays. Another resident, with severe cognitive impairment and incontinence, also experienced delayed responses to call lights, with logs indicating response times between 15 and 63 minutes. This resident required substantial assistance for activities of daily living and care in pairs. The resident reported discomfort and embarrassment from waiting to be changed after incontinence episodes. Staff interviews confirmed that delays occurred, particularly for residents needing two staff members for care, and acknowledged that these delays could result in residents remaining in soiled briefs for extended periods. Staff, including nursing assistants and the RN, acknowledged that while the facility had enough staff to answer call lights, the need for two staff members to assist certain residents contributed to longer wait times. The facility's policy required call lights to be answered as soon as possible, and the expectation was a response within 10-15 minutes. However, documentation and interviews confirmed that this standard was not consistently met, leading to residents experiencing incontinence and loss of dignity while waiting for assistance.