Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care for two residents, as required by its own policies. One resident, with multiple diagnoses including cerebral infarction, hemiplegia, and diabetes, was documented as requiring staff assistance for activities of daily living and regular incontinence checks. Despite this, there were instances where the resident was left for extended periods without being checked or changed, resulting in the resident remaining in soiled conditions. Family members reported that staff did not return to provide care after being notified, and on one occasion, a family member had to clean the resident themselves, finding dried feces and causing discomfort and skin irritation to the resident. Another resident, who was cognitively intact and required assistance with toileting, experienced significant delays in response to call lights. Observations showed that the resident's call light was on for over 20 minutes before assistance was provided, during which time the resident was left waiting to use the bathroom. The resident reported that such delays had previously caused her to be incontinent, which she found distressing. Staff confirmed that staffing levels were insufficient to meet the needs of the residents in a timely manner, particularly during busy periods such as morning care routines. The facility's policies require that call lights be answered promptly and that incontinent residents be checked at least every two hours, with perineal care provided after each episode. However, the documented events show that these policies were not consistently followed, resulting in residents experiencing prolonged periods without necessary care and assistance, and being left in uncomfortable and undignified situations.