Failure to Provide Timely Incontinence Care Resulting in Neglect and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from neglect and verbal abuse, as evidenced by two residents not receiving incontinence care for an extended period. Both residents reported to a nurse aide that they had not received incontinence care since early morning, and care was not provided until after lunch. The assigned nurse aide was observed using her personal phone at the nurses' station and did not communicate the residents' needs to other staff. Witness and resident statements confirmed the neglect, despite the initial facility investigation being unverified. Further review revealed that one resident's spouse found the resident in a soiled and disintegrated brief, with the resident exhibiting redness in the groin area. A nurse was observed cleaning the resident and expressed anger about the situation. The resident's spouse noted that the resident rarely had skin issues prior to admission. An LPN later found the resident without a brief, with a strong urine odor and pieces of the brief on the floor, and had to request housekeeping assistance. Documentation confirmed a new in-house wound described as incontinence-associated dermatitis.