Failure to Maintain Resident Dignity and Timely Incontinence Care
Penalty
Summary
A resident with a history of type 2 diabetes, morbid obesity, and bilateral lower extremity amputations was found to have her dignity and respect compromised due to delayed response to call lights and incontinence care. The resident, who was alert and oriented, reported being left in bed soiled with feces for nearly four hours on more than one occasion. She specifically identified a CNA who failed to provide timely assistance with activities of daily living and responded to her requests for help in a harsh and dismissive manner. The resident also described experiencing severe pain and spasms, requiring assistance for toileting, and reported her concerns to various staff members, including nurses and the ombudsman. Interviews with staff and outside agency visitors corroborated the resident's account. The charge nurse recalled the resident reporting being left soiled for prolonged periods and confirmed that the CNA in question was subsequently removed from assignment to the resident's floor. Outside agency representatives witnessed the resident lying on urine-saturated linen, with staff placing a dry pad on top due to a reported linen shortage. These agency visitors also observed delayed call light responses, with the resident left waiting for over 40 minutes while staff were seen socializing at the nurses' station. The resident expressed feeling retaliated against and blamed by staff after voicing her concerns. Facility policy reviews indicated that residents are to be treated with dignity and respect at all times, and that grievances should be addressed promptly without discrimination or reprisal. Despite these policies, the resident's experiences and the observations of outside agencies demonstrated a failure to uphold these standards, resulting in the resident being left in soiled conditions and feeling disrespected and anxious.