Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care to two residents who were dependent on staff for activities of daily living (ADLs). Both residents had activated their call lights to request assistance with being changed due to incontinence, but their calls went unanswered for at least 20 minutes. One resident reported needing to be changed, while the other stated she was soiled and had diarrhea. During this period, staff were not present to respond to the call lights, and when a CNA returned from a lunch break, she turned off one resident's call light without providing care, confirming she was unaware that no one had been available to answer the calls. Medical record reviews indicated that both residents had significant medical conditions, including cerebral infarction, diabetes, depression, and dementia, and were assessed as requiring substantial to total assistance for ADLs. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and personal care. The failure to respond to call lights and provide timely incontinence care was observed and confirmed through resident and staff interviews, as well as review of facility policy.