Failure to Provide Dignified Incontinence Care
Penalty
Summary
Facility staff failed to provide care in a dignified manner for one resident who was observed from 10:07 a.m. to 5:30 p.m. without being offered incontinence care. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken back to her room for incontinence care. Continuous observation confirmed that no staff member provided or offered incontinence care throughout the entire period. Interviews with CNAs and an LPN confirmed that incontinent residents should be checked at least every two hours, with some requiring more frequent checks, especially those unable to communicate their needs. Staff acknowledged that failing to provide timely incontinence care can lead to skin breakdown and is not consistent with treating residents with dignity. Facility management agreed that lack of incontinence care for an extended period could result in emotional distress and a diminished quality of life for the resident.