Failure to Maintain Resident Dignity in Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that maintained resident dignity and honored resident rights related to toileting and incontinence care. One resident with adjustment disorder, diabetes mellitus, hypertension, and a BIMS score of 12 reported that staff made her use a bedpan for bowel movements despite an active physician order for use of a bedside commode at the bedside with assistance of two for transfers. She stated that the bedside commode had been removed from her room and not returned, and that when she requested it, staff told her to use the bedpan instead. Review of her clinical record confirmed the ongoing physician order for bedside commode use, indicating that staff were not following the order and were not honoring her expressed preference for the commode. Another resident with traumatic brain injury, end stage renal disease, diabetes mellitus, and a BIMS score of 15, who was dependent for toileting hygiene and toilet transfers, filed a grievance stating that he went from 9:30 a.m. to 8:30 p.m. without having his brief changed. He reported calling for a nurse multiple times, speaking with a nurse aide around 4:30 p.m. who said she would return but did not, and that after his daughter called the facility in the evening, a nurse came but it then took an additional 30–40 minutes to find an aide to change him. A third resident with similar diagnoses and a BIMS score of 15, requiring substantial/maximal assistance for toileting hygiene, filed a grievance stating she was placed on a bedpan at 10:15 p.m., fell asleep, and awoke at 11:43 p.m. still on the bedpan, after which she called staff to have it removed. In an interview, the Nursing Home Director and Director of Nursing confirmed the facility failed to ensure care was provided in a manner that maintained resident dignity, in violation of resident rights requirements.
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