Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves multiple cognitively intact residents being left wet or soiled for extended periods, particularly during night shifts staffed by agency CNAs, in violation of their right to dignified care. One resident with frequent bowel and bladder incontinence reported that on a specific overnight, she activated her call light multiple times requesting toileting assistance, observed two agency CNAs pass her room without responding, and ultimately fell asleep with the call light on. She awoke soaked in urine on several occasions, again turned on the call light, and no staff responded; she stated she lay in a wet incontinence brief and saturated bed linens the rest of the night and felt neglected and ashamed. Day-shift CNAs later found her with fully saturated linens requiring a full bed change and total bed bath, and she reported the incident to her nurse. Day-shift CNAs corroborated a pattern of residents not being checked or changed overnight when agency CNAs worked, describing repeatedly finding residents, including this resident, with incontinence briefs “wringing wet” and bed linens showing multiple rings of dried and fresh urine and feces, indicating they had not been changed during the night. One CNA stated she could not count how many times she had found this resident’s bed saturated in the morning and that the resident was not a heavy wetter, while another CNA described following night agency staff and finding residents’ beds totally saturated, with obvious evidence that residents had not been changed on two-hour rounds. A CNA and the DON both characterized these situations as dignity issues, and the DON stated residents are to be checked every two hours on all shifts and as needed. Additional residents with no cognitive impairment and bowel and bladder incontinence reported similar experiences of not being checked or changed overnight when agency staff were on duty. One resident stated she had laid in her own incontinence for hours and believed the problem was with agency staff. Another resident, who was always incontinent and required a full-body mechanical lift, was observed by a CNA asking two CNAs to be cleaned and gotten out of bed while she had diarrhea; the CNAs told her she could not get up and that they would not change her, stating she was not finished yet. The observing CNA reported this to an RN and then returned to clean the resident herself, finding her sheets soiled and her brief full, while the resident repeatedly thanked her and said she could not stand lying in her own feces any longer. The RN later acknowledged that if CNAs told the resident she could not get up and had to remain soiled, it was not appropriate and was a dignity issue. Another resident stated that when agency staff worked nights, nobody checked on them, and that lying in urine all night made them feel horrible and like a burden.
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