Failure to Maintain Resident Dignity During Incontinence Episodes
Penalty
Summary
Facility staff failed to ensure a resident's dignity and respect by not promptly addressing episodes of incontinence while the resident was in common areas. Multiple observations documented the resident seated in a wheelchair with visibly wet clothing and a strong odor of urine, remaining soiled for extended periods in public spaces. Staff, including a CNA and a Nurse Practice Educator, were aware of the resident's condition but did not immediately provide assistance until the resident specifically requested a brief change. The resident reported having to wear two briefs due to inadequate absorbency and stated that staff would not change her unless she asked. Interviews with the resident's POA revealed ongoing concerns about hygiene and cleanliness, with the POA noting that the resident frequently complained about not being clean and required a new outfit after being soiled during a medical appointment. Staff interviews indicated that while some CNAs monitor incontinent residents and address needs regardless of assignment, this was not consistently practiced. The resident ultimately requested the re-insertion of a foley catheter due to infrequent changes and embarrassment from being soiled in public and during medical visits. The DON stated that staff are expected to complete rounding but cannot force residents to accept care, though there was no indication in the report that the resident refused care during the observed incidents.