Failure to Provide Timely Incontinent Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure timely and adequate incontinent care for two residents, resulting in a lack of dignity and compromised grooming. For one resident, who had morbid obesity, diabetes, hypertension, and required assistance with personal care, observations revealed that her incontinent brief was saturated with urine and brown in color, indicating it had not been changed for an extended period. The resident reported that she had only been changed once that day and that her requests for care were not promptly addressed. Staff interviews confirmed that the resident was not checked or changed every two hours as required by her care plan, and the responsible aide did not communicate the lack of care to the nursing staff. Another resident, also with morbid obesity, diabetes, hypertension, and a history of cerebral infarction, required total assistance with activities of daily living. This resident reported not being changed by the morning aide and feeling dirty and upset due to the delay. Upon assessment, her incontinent brief, draw sheets, and air mattress were found to be soaked with urine, and the brief was brown inside, indicating prolonged exposure. Staff interviews corroborated that the resident had not been changed for hours, and aides acknowledged the expectation to provide care every two hours, which was not met in this instance. Facility policy and staff statements confirmed that incontinent care should be provided at least every two hours and as needed, regardless of the resident's size or condition. Both residents expressed negative feelings about being left in soiled briefs, and staff recognized that such lapses in care were unacceptable. The documentation and interviews consistently showed that the facility did not adhere to its own policies or the residents' care plans, resulting in a failure to honor the residents' rights to dignity and timely personal care.