Failure to Provide Adequate Incontinent Care and Violation of Resident Privacy
Penalty
Summary
A male resident with multiple diagnoses, including heart failure, malnutrition, fecal urgency, and muscle weakness, was found to have not received adequate incontinent care as required by his care plan. The care plan specified that the resident, who was always incontinent of bladder and bowel and at risk for skin breakdown, should be checked every two hours, have peri care after each incontinence episode, and have barrier cream applied. Despite these interventions being documented, the resident was found by a family member to be sitting in a recliner with dried, caked-on feces and dried urine on his legs and the floor around him, indicating he had been soiled and wet all night. The family member, a retired nurse, described the situation as negligent and cruel, and noted that while some CNAs performed the required checks, others did not. Staff and resident signatures were required on changing sheets, and a sign in the resident's room reminded staff of the two-hour checks. Interviews with staff revealed inconsistent adherence to the two-hour check protocol. The DON confirmed that all staff were responsible for these checks and that nurses were to ensure compliance. However, several staff members, including CNAs and nurses, either denied knowledge of the incident or stated that the resident was found in a severely soiled state, with some describing the situation as neglectful. One CNA, who was assigned to the resident's hall, was reported by colleagues to frequently neglect her duties, spend time on her phone, and avoid resident care. This CNA admitted to checking on the resident last at 4:00 am but failed to chart the care provided. The incident was not documented in the resident's progress notes for the date in question. Additionally, staff took unauthorized photographs of the resident in the soiled condition, which violated facility policy regarding resident privacy and dignity. The facility's policies explicitly prohibit taking or distributing photographs of residents in compromising situations without consent, as this constitutes mental abuse and a violation of resident rights. Multiple staff members acknowledged seeing the photos, but it was unclear who took them. The facility's policies also define neglect as the failure to provide necessary care to avoid physical harm or emotional distress, and the events described met this definition according to staff interviews and policy review.