Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The facility failed to honor a resident's right to dignity and respect during incontinence care by applying multiple incontinent briefs at one time. The resident had diagnoses including sepsis, weakness, and required assistance with personal care, with an MDS indicating intact cognition (BIMS 15/15) and dependence on staff for toileting hygiene and transfers. The resident’s care plan required assistance of two staff for toilet transfers, noted urinary incontinence, and directed staff to assist the resident to the bathroom and with cleansing, but did not include the use of more than one incontinent brief. Facility policy on dignity stated that care would be provided in a manner that promoted well-being, satisfaction with life, self-worth, and self-esteem. Documentation showed that on the morning of 11/29/25, CNA Staff C was assigned to and provided care for the resident on the 300 Hall, and the resident was later transferred to the hospital that morning. A hospital shift summary dated 12/2/25 documented that the resident arrived at the hospital in three pairs of grossly soiled diapers with skin damage. An internal investigation witness statement recorded that the DON interviewed Staff C, who stated she had taken care of the resident on that Saturday morning. CNA Staff A reported that when she first started at the facility, Staff C instructed her to place more than one brief on residents, but she chose not to follow this practice. CNA Staff B stated she had observed Staff C placing more than one brief on residents, including this resident, and that she last told Staff C not to do this on 11/28/25, though she did not report it immediately because she was concerned about Staff C’s job. The DON later stated that staff should only apply one brief to residents unless otherwise directed in the care plan, and confirmed that this resident’s care plan did not authorize the use of more than one incontinent brief.
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