Failure to Provide Dignified Incontinence Care Before Off-Site Appointment
Penalty
Summary
Facility staff failed to provide dignified care to a quadriplegic resident with a traumatic brain injury and hydronephrosis who was moderately cognitively impaired and dependent on staff and a mechanical lift for incontinence care and transfers to bed. The resident routinely went to the hospital every two weeks for a urinary procedure. On the night before one such scheduled procedure, the resident reported that staff refused to transfer him from his power chair to bed, resulting in him sleeping in his chair. The next morning, prior to transport for the appointment, the resident stated he repeatedly requested to be cleaned after soiling himself while sitting in the hallway, but staff did not provide the requested care before he left for the hospital. Hospital records for that appointment documented that the resident arrived very upset, reported that facility staff had made him sit in his wheelchair all night, and was found with multiple pressure injuries on his buttocks with dressings saturated with old and new stool and extensive redness of the buttocks. A hospital RN confirmed the resident had a strong stool odor, that staff there had to clean old and new stool and change three stool-soiled dressings, and that the smell permeated the unit while the resident expressed embarrassment and frustration. Facility staff interviews indicated that floor staff were responsible for preparing residents for transport and that the resident was known to be incontinent of stool and required a mechanical lift for changing, but there was no documentation in the EMR of the resident leaving for the appointment, of any refusal to go to bed or refusal of care on the dates in question, or of behavior symptoms related to rejection of care. Bowel movement documentation did not reflect a bowel movement around the time of transfer, and there was no record that staff checked or cleaned the resident before transport.
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