Failure to Provide Timely Incontinence Care and Response to Call Light
Penalty
Summary
The facility failed to provide routine incontinence care and timely assistance to a resident with severe cognitive impairment, frequent urinary incontinence, and occasional bowel incontinence. On multiple observations, a strong odor of urine and feces was noted from the hallway outside the resident’s room. The resident was found lying in bed in a fetal position with the bottom sheet pulled off the mattress and gathered around her, and a top sheet draped over her torso and lower body. Feces was observed on the pillowcase, sheets, fitted sheet, and mattress, as well as on the resident’s hands and under her fingernails. The resident repeatedly stated she was cold, soaking wet, and needed to be cleaned up, and reported she had not gotten out of bed that day. The resident activated her call light, which was confirmed to be functioning as indicated by the illuminated light above the door. An unidentified male staff member entered the room, was informed by the resident of her need for cleaning and warmth, turned off the call light, stated he would try to get an aide, and then left without providing care. No staff entered the room for at least 29 minutes after the call light was activated, during which time the resident continued to call out for help. Later observations showed the resident still soiled and shivering, yelling for help with no staff visible in the hallway. An LPN/Unit Manager briefly entered and exited the room, verbally noting the resident wanted to get up, but did not return to assist. A CNA could not state when the resident last received care. The resident expressed anger, frustration, helplessness, sadness, and a desire to leave the facility due to not being cared for. The facility’s abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress.
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