F0600

E

Failure to Provide Required Incontinence Rounds and Safety Checks Resulting in Resident Neglect

Buffalo, New York Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect multiple residents from neglect by not providing incontinence care and safety checks as required by their care plans and facility policy. Facility policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and required CNAs to provide incontinence care or toileting every 2–4 hours and to round on residents at least every 1–2 hours, including checking that residents were dry and toileted appropriately. Despite these requirements, video footage, staff interviews, and family reports showed that assigned staff did not perform required rounds or incontinence checks for numerous residents during night shifts.

One resident with quadriplegia, diabetes mellitus, neuropathic bladder, moderate cognitive impairment, and total dependence on staff for toileting was care planned to be toileted every morning, after meals, and at bedtime, and to be checked for incontinence and provided care every 2–3 hours and as needed. On multiple nights, the resident’s spouse reported finding the resident at approximately 5:30 AM soaked with urine, with saturated briefs, pads, linens, and mattress, and brown rings on the brief. Video review for the relevant nights showed that one CNA did not enter the resident’s room at all between 11:00 PM and 5:30 AM on one date, and on two other dates another CNA entered the room only once for a few minutes and exited without any soiled linens. The resident and family member stated that no one would enjoy lying in a wet bed and described the situation as undignified and neglectful. Facility leadership and the Assistant DON confirmed that required 2–3 hour rounds and incontinence checks were not completed for this resident and that other residents on the same unit were also not checked as required.

Another group of residents, including individuals with hemiplegia, cerebral palsy, diabetes mellitus, seizures, severe cognitive impairment, and total or extensive dependence on staff for toileting and incontinence care, were similarly affected on a different night. Care plans and Kardex instructions for these residents required incontinence care every 3–4 hours, toileting offers every 3 hours, and keeping skin clean and dry. A complaint was received that residents on a specific pod appeared soaked and unchanged during an overnight shift. A nurse entering the unit in the morning noted a foul odor and was informed that none of the residents had been “touched” during the 11:00 PM to 7:00 AM shift, and one resident was found covered in feces. Video footage and timelines reviewed by the Assistant DON showed that the assigned CNA did not provide care to the residents on that pod during the shift. Staff interviews corroborated that call lights were going off while the CNA was at the secretary’s desk, that the CNA did not bring linens out of rooms, and that residents with dementia could not report their needs and therefore relied on staff to ensure they were dry and comfortable. Facility leadership stated that residents were left wet and not cared for per their care plans and that no resident should go untouched for eight hours.