Failure to Maintain Resident Dignity and Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a male resident with dementia, muscle weakness, and frequent bowel incontinence was found lying sideways on his bed, covered in dried feces, and wearing a full, soiled brief. The incident was documented with a photograph showing brown stains consistent with fecal matter on the resident, his brief, and the bed sheets. The resident's care plan included interventions for checking and changing him, and his records indicated a medium bowel movement earlier that day, but there were no further entries or progress notes documenting additional care or checks on the date of the incident. Interviews with multiple staff members, including CNAs, LVNs, the ADON, and the DON, revealed that facility policy and staff understanding required residents to be checked and changed every two hours or as needed. Staff were expected to document these activities in the resident's POC, but there was inconsistency in oversight and documentation practices. Some staff were unsure who was responsible for ensuring that checks and changes occurred as scheduled, and there was no evidence of in-service training related to dignity and resident rights during the relevant period. The resident's representative reported observing the resident in this undignified state, and staff acknowledged the importance of regular checks and changes to maintain dignity and prevent skin breakdown. Facility policies reviewed emphasized the need to treat residents with dignity and respect, maintain privacy, and document perineal care, but these standards were not met in this instance, resulting in the resident being left in soiled conditions without timely intervention or documentation.