Failure to Provide Timely Incontinence Care Results in Resident Neglect
Penalty
Summary
The facility failed to provide timely and adequate incontinence care for two residents, resulting in both being left saturated in urine for extended periods. One resident with paranoid schizophrenia and anxiety, who required one-person assistance with toileting, reported being left in urine all day without staff assistance, leading to feelings of humiliation and distress. Staff interviews revealed inconsistent documentation and communication regarding the resident's care needs and refusals, with one CNA admitting she did not know the resident was incontinent and failed to report alleged refusals of care. The resident was ultimately found by night shift staff to be soaked in urine, with saturated bedding and visible emotional distress. Another resident with dementia and anxiety, who was care planned for bladder incontinence and required regular checks and assistance, was also found lying in bed without clothing or a brief, saturated in urine. The resident expressed feelings of disgust and humiliation due to being left in soiled conditions for hours. Staff interviews indicated that the resident was known to be resistant to care and sometimes removed soiled items herself, but there was no documentation of care refusals or interventions attempted during the relevant shift. Day shift staff did not provide incontinence care, citing the resident's combative behavior and a lack of report on her status. Facility leadership confirmed that staff are expected to check and change incontinent residents every two hours and document any refusals of care, with further interventions required for continued refusals. However, in both cases, there was a lack of documentation, communication, and timely intervention, resulting in neglect as defined by regulatory standards. Both residents experienced psychosocial harm, including feelings of shame, humiliation, and emotional distress, as a direct result of being left in their own incontinence for prolonged periods.