Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. The resident, an older male with multiple diagnoses including chronic obstructive pulmonary disease, muscle weakness, major depressive disorder, vascular dementia, type II diabetes mellitus, and paranoid schizophrenia, was noted to have severe cognitive impairment and was always incontinent of bowel and bladder. His care plan required frequent checks for incontinence and regular cleaning of his room due to his risk for unsanitary behaviors and falls. On the day of the survey, the resident was found sitting in his wheelchair, naked from the waist down, with wet pants on the floor and dried feces smeared from the toilet to the sink. The room had a strong odor of urine and feces, sticky floors, and a pool of liquid identified by the resident as urine. The resident reported that no one had checked on him since breakfast, and he felt bad about the soiled conditions. Staff interviews revealed that the assigned CNA did not perform required rounds or check the care plan, assuming the resident could toilet himself. The CNA acknowledged that the resident was left in an undignified state and that frequent checks were necessary due to his incontinence and behavioral issues. Further interviews with the LVN and DON confirmed that the resident required frequent monitoring and that the room should have been cleaned at least twice daily. The LVN admitted not checking on the resident during the morning hours due to being busy with medications, and the DON stated that the resident's condition and room were unacceptable. Facility records showed that staff had received training on resident rights and dignity, and the facility's policy required all residents to be treated with kindness, respect, and dignity.