Failure to Maintain Resident Dignity During Incontinence Episodes
Penalty
Summary
Facility staff failed to ensure a resident's dignity and respect by not promptly addressing episodes of incontinence while the resident was in common areas. Multiple observations documented the resident seated in a wheelchair, visibly wet from the lower shirt to the knees, and remaining soiled for at least 15 minutes in a public area. The resident reported having to wear two briefs due to inadequate absorbency and stated that staff would not change her unless she specifically requested it. Staff interviews confirmed awareness of the resident's condition, with one CNA acknowledging the resident was wet and another stating that any certified staff should assist with changing a soiled resident, regardless of assignment. Additional observations noted a strong odor of urine and the resident remaining wet after moving between common areas, with staff present but not intervening until the resident directly requested assistance. The resident's Power of Attorney expressed concerns about the bathing schedule and the resident's ongoing complaints about not being clean. The resident had a history of incontinence, previously managed with a foley catheter, which had been removed three months prior. After continued issues with incontinence care, the resident requested the catheter be reinserted, citing embarrassment and discomfort from being soiled, including during a medical appointment. The Director of Nursing stated that staff are expected to complete rounds but cannot force residents to accept care, noting that some residents refuse assistance. However, the report documents that the resident was not offered timely care and was left soiled in public areas, impacting her dignity.