Delay in Incontinence Care and Compromised Resident Dignity
Penalty
Summary
Staff failed to provide timely incontinence care for a resident who was always incontinent and required substantial to maximal assistance with toileting hygiene. The resident, who was cognitively intact and had a diagnosis of hereditary spastic paraplegia, reported being changed at approximately 3 p.m., became wet again about 30 minutes later, and notified staff but remained wet for about an hour. During this period, a strong urine odor was observed in the resident's room. The CNA acknowledged the resident was wet but left the room twice without providing care, only returning to change the resident after a significant delay. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the expectation was for incontinence care to be provided every two hours and as needed, with communication to the resident if there was a delay. Facility policy emphasized the importance of promptly responding to resident requests for toileting assistance and maintaining resident dignity. The observed delay in care did not align with these expectations and resulted in the resident remaining in a soiled brief for an extended period.