The resident, who requires maximum assistance for basic care including toileting and personal hygiene, said during a July 8 interview that night shift staff would not change him before 4:30 am. He described multiple situations where urine had soaked his entire back and pillow.
"Some of staff are incompetent or do not want to do their job," the resident told inspectors. He said he should be changed at minimum twice per shift and had even requested a sign be posted above his bed indicating this need.
A certified nursing assistant working day shift corroborated the resident's account during her July 9 interview with inspectors. The CNA said she would arrive for her 7 am shift and find residents from the night shift still soiled.
The assistant specifically confirmed the resident's statement about being left wet with urine "to the point where the sheets soaked through and dripping because night shift staff failed to assist the resident."
The resident was admitted to the facility with multiple serious conditions including monoplegia of his left non-dominant side, muscle weakness, anxiety, type 2 diabetes, chronic obstructive pulmonary disease, and a urinary tract infection. Despite these conditions, his March medical evaluation indicated he retained the capacity to understand and make decisions about his care.
His June assessment showed he required staff supervision for eating and maximum assistance to total dependence for bed mobility, toileting, dressing, and personal hygiene.
The facility's Director of Nursing acknowledged during her July 9 interview that best practices for incontinence care require changing residents at least twice per shift. She told inspectors it was "unacceptable to leave a resident for hours without changing the resident."
This acknowledgment directly contradicted what was happening on the night shift, where the paralyzed resident described being left in his own urine for extended periods.
The facility's own policy on pressure injury prevention, last revised in April 2020, requires staff to "keep the skin clean and hydrated" and "clean promptly after episodes of incontinence." The policy recognizes that proper skin care is essential for preventing serious complications in residents who cannot move independently.
For residents with paralysis, prolonged exposure to urine can cause skin breakdown, infections, and painful pressure sores. The resident's multiple medical conditions, including diabetes, make him particularly vulnerable to these complications.
The inspection occurred following a complaint about conditions at the facility. Federal regulators investigated on July 9, conducting interviews with the affected resident, nursing staff, and facility leadership.
The resident's experience illustrates the gap between written policies and actual care delivery during overnight hours, when fewer supervisors are present and residents may go longer periods without attention.
His request for a sign above his bed suggesting the need for regular changes shows his awareness of his own care needs and his attempt to advocate for basic dignity. The fact that he still experienced prolonged exposure to urine despite this measure highlights systemic failures in the facility's approach to resident care.
The certified nursing assistant's observation that multiple residents were found soiled at the start of day shifts suggests the problem extended beyond this single resident. Her willingness to confirm the resident's account during the federal inspection indicates the issue was well-known among staff.
The Director of Nursing's statement that such treatment was unacceptable, combined with the documented policy requiring prompt cleaning after incontinence, establishes that facility leadership was aware of proper standards but failed to ensure their implementation during night shifts.
The resident remains at Sunray Healthcare Center, dependent on staff who have demonstrated they will leave him wet for hours despite his paralysis, medical vulnerabilities, and explicit requests for more frequent care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunray Healthcare Center from 2024-07-09 including all violations, facility responses, and corrective action plans.