Failure to Provide and Document Required Toileting Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL), specifically toileting, for one resident who was dependent on staff for this care. The resident had diagnoses including dementia, muscle weakness, and required assistance with personal care. According to the resident's care plan and assessment, the resident was frequently incontinent of urine and dependent on staff for toileting hygiene and transfers. Documentation from the electronic charting system showed that toileting assistance was either not provided or not documented on multiple shifts over a one-week period. In several instances, the activity was marked as 'did not occur,' and on other shifts, there was no documentation of toileting assistance at all. Interviews with staff, including a CNA, Unit Care Coordinator, and DON, confirmed that the expectation was for residents to be offered toileting assistance at least every two hours and for this care to be documented at least once per shift. Staff acknowledged that documentation of 'activity did not occur' meant the care was not provided, and there was no evidence that the required assistance was given or properly documented on the specified dates. The resident's representative also reported an incident where the resident was changed only once in an eight-hour period, resulting in urine soaking through their briefs.