Resident Dignity Compromised Due to Delayed Incontinence Care
Penalty
Summary
Capitol Rehabilitation and Healthcare Center was found to be non-compliant with resident rights requirements as outlined in 42 CFR Part 483, Subpart B. The deficiency involved a failure to provide care in a manner that enhanced the dignity of a resident diagnosed with benign prostatic hyperplasia, dementia, and anxiety disorder. On December 23, 2024, the resident was observed sitting in a dining area with a puddle of urine beneath his chair, indicating incontinence. Despite this, the resident was wheeled back to the same spot by a nurse aide, leaving him in an undignified state. Further observations revealed that the resident remained in the dining area without receiving incontinence care until prompted by a surveyor's inquiry. The Director of Nursing confirmed that the resident was incontinent and that a nurse aide had been informed of the need for incontinence care but was sidetracked by other tasks. This delay in providing necessary care until the surveyor's intervention highlighted a lapse in maintaining the resident's dignity and timely care.
Plan Of Correction
1. Resident 1 did not have any adverse reactions. 2. The residents in the North Dining Room will be monitored by the LPN to ensure that the residents are being checked q 2 hours for incontinent care. 3. Nursing staff will be educated on customer service and checking and changing the residents q 2 hours by the DON/Designee on 1/6/2025. 4. DON/Designee will QA weekly for 4 weeks, then monthly to ensure residents are being checked and changed q 2 hours. Results to be reviewed with the QAPI committee. 5. Compliance by 1/21/2025.
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