Failure to Provide Dignified Incontinence Care and Clean Environment During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity, including maintaining cleanliness and appropriate incontinence care. The resident had diagnoses of CVA, schizophrenia, and intellectual disability, was severely cognitively impaired, and required total assistance for personal hygiene and toileting, with documented bowel and bladder incontinence. The resident’s care plan and Kardex specified total assistance for hygiene and toileting but did not include specific interventions or instructions for managing bowel and bladder incontinence. On the survey date, the resident was observed in bed wearing only an incontinent brief, a small blanket, and a flat sheet that was visibly soaked and soiled with urine from shoulders to the foot of the bed. Between the bed and the wall, there were multiple soiled flat sheets, a soiled brief, a large amount of feces, and dried food debris on the floor. Later the same day, the resident remained in bed on the heavily soiled sheet while their lunch tray, which had been fully consumed, sat on the overbed table, and the soiled linens, brief, feces, and food debris remained on the floor. CNA staff reported that the resident had been washed and provided incontinence care earlier in the morning and acknowledged that incontinence care should be provided every two hours, that they had not returned to the room since the morning, and that the resident should have been cleaned before receiving lunch. Video surveillance showed that the same CNA delivered the lunch tray shortly before the resident was observed eating while still soiled. Although the bed linens were later changed, the dried food debris and large amount of feces remained on the floor behind the bed. The unit manager, corporate DON, and a family member all stated that the resident should have been provided care and that the situation was undignified, with the family member reporting that the resident was always soiled with urine and feces during visits and that prior complaints to staff had not resulted in changes.
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