Failure to Provide Timely Incontinence Care Compromising Resident Dignity
Penalty
Summary
The facility failed to provide timely incontinence care for three residents who were dependent on staff for toileting and hygiene, resulting in prolonged periods where residents remained soiled. One resident, with diagnoses including muscle weakness, ESRD, and impaired cognitive skills, was left sitting in a soiled incontinence pad for approximately six hours after a bowel movement. The resident had requested assistance multiple times, but after refusing care from the assigned CNA, no alternative staff was arranged in a timely manner. The CNA did not inform the charge nurse when unable to secure another CNA, resulting in a significant delay before care was provided. Another resident, who required partial to moderate assistance for toileting and was at risk for pressure ulcers, experienced a delay of about an hour before receiving incontinence care. The resident had requested to be cleaned and was told by the CNA that care would be provided after attending to another resident. Due to staff shortages, the resident remained soiled for an extended period, which the CNA acknowledged could place the resident at risk for skin breakdown and affect their dignity. A third resident, with hemiplegia and requiring substantial assistance for toileting, also experienced excessive wait times for incontinence care. The resident and a family member reported waiting up to an hour and a half for pericare, with the resident stating that staff did not change her throughout the night shift. The assigned CNA confirmed the delay, citing being occupied with other residents and additional duties. Facility policies reviewed indicated that staff were required to promptly respond to toileting requests and maintain residents' dignity, but these standards were not met in the cited incidents.