Failure to Ensure Dignity Related to Call Light Response and Incontinence
Penalty
Summary
Surveyors identified a failure to ensure dignity and respect related to call light response for four residents. One resident with moderately impaired cognition and frequent urinary and occasional stool incontinence reported that when staff did not answer her call light and she had to go to the bathroom, she sometimes had accidents that did not feel good and embarrassed her. Another resident with intact cognition and frequent urinary incontinence due to taking a diuretic stated she was always incontinent but, when she had to wait, she thought about other residents who also needed help and were not getting it. A third resident with intact cognition and occasional urinary incontinence reported that it took a long time for night shift to answer her call light, so she would get up and go to the bathroom on her own. A fourth resident with intact cognition and occasional urinary incontinence stated that if she had to wait a long time to use the toilet and had an accident, it made her feel awful. Staff interviews further described conditions contributing to delayed call light response. A night-shift LPN reported that they usually staffed 2 to 3 CNAs for three units (100, 200, 400) and 1 CNA for the memory care unit at night, and stated that this was not enough CNAs to get everything done and that 1 CNA was not enough on the unit. A CNA reported that management did not answer when staff tried to contact them, including call nurses, and stated that night shift did not have enough staff and that they needed 5 CNAs on nights, including 2 on the memory unit. Additional CNAs stated they tried to answer call lights as soon as possible and acknowledged that, if they themselves had urinated on themselves while waiting for a call light to be answered, they would feel embarrassed. The Ombudsman Residents' Rights document cited by surveyors stated that the facility must provide services to keep residents' physical and mental health and sense of satisfaction with themselves at their highest practical levels.
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