Failure to Provide Timely Incontinent Care and Respond to Call Lights
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The resident, who had multiple medical diagnoses including congestive heart failure, hypertension, diabetes, stroke, COPD, and parkinsonism, was totally dependent on staff for most ADLs, including incontinent care. The care plan for this resident specified that call lights should be within reach and answered promptly, but this intervention was not consistently followed. Over a period of several months, the resident's call light was repeatedly ignored or not acknowledged by the 3rd shift nursing staff, particularly for incontinent care needs. Documentation and interviews revealed that the resident was left in soiled conditions for extended periods, sometimes for several hours, and that staff would enter the room, turn off the call light, and leave without providing care. The resident and her family member reported multiple instances of neglect, including verbal abuse and dismissive behavior from staff, and these concerns were corroborated by the resident's roommate and a CNA. Despite these ongoing issues, management staff and the administrator denied receiving complaints or being aware of the neglect, and incident reports did not reflect the call light concerns. The resident expressed feelings of neglect, belittlement, and shame as a result of the staff's actions and inactions. Interviews with other staff members confirmed that complaints about call lights not being answered, especially on the night shift, were known but not always reported or addressed. The facility's policy required staff to treat residents with kindness, respect, and dignity, but this was not upheld in the care provided to the resident during the period in question.