Failure to Maintain Resident Dignity and Provide Timely Incontinence and Device Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living and incontinence care, resulting in a resident being left in soiled conditions on two separate occasions. The resident was an elderly male with dementia, dysphagia, esophageal obstruction, colostomy status, ileus, and intestinal obstruction, who was dependent on staff for toileting and incontinent care and had both an indwelling catheter and an ostomy. His care plan and orders required staff to monitor and manage his colostomy and feeding tube, provide extensive assistance with ADLs, and assist with incontinent care and repositioning. On one evening, a family member reported that after visiting the resident, cleaning him, changing his bed sheets, and cleaning his floor, she left and returned about an hour later to find him covered in feces. A photo from that date showed the resident lying in a light brown liquid substance on his colostomy bag, stomach, adult brief, bedsheets, and clothing. The family member brought the Unit Manager and an RN to the room and requested that the resident be showered. The Unit Manager and RN later confirmed that they recalled the incident, described the colostomy bag as leaking, and stated that they did not know how long the resident had been in that condition. On another occasion, the same family member reported that when she visited and removed the sheet from the resident, his adult brief was open underneath him and the bed was soaked with urine and tube-feeding formula. A photo from that date showed an open adult brief with light tan stains and bed sheets soaked with a light tan substance. The family member called an LVN to the room and showed him the condition. Staff interviews, including with the Unit Manager, RN, DON, Administrator, and LVN, acknowledged that the resident’s colostomy and feeding tube frequently leaked, that residents were supposed to be checked every two hours or more frequently as needed, and that the resident would need to be checked more often due to frequent leakage. The facility’s ADL policy stated that necessary assistance and supervision would be provided when residents were unable to perform ADLs independently.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.