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F0677
D

Delay in Providing Timely Toileting Assistance

West Salem, Wisconsin Survey Completed on 04-14-2025

Penalty

Fine: $278,155
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident who required extensive assistance for toileting was not provided timely care after requesting to use the bathroom. The resident, who had a history of orthopedic aftercare following surgical amputation, was non-weight bearing on the right leg, and required the use of a Hoyer lift with assistance from two staff members, asked a CNA for help to use the bathroom. The CNA informed the resident that she was on a two-hour toileting schedule and would need to wait, despite the resident not being on such a schedule according to her care plan. The resident waited approximately 1 hour and 20 minutes before being assisted to the bathroom. During this period, staff communication and follow-through were lacking. The CNA who received the request prioritized other residents and did not seek immediate assistance from other staff, even though the Director of Nursing later clarified that staff are expected to respond to such requests as soon as possible. Another CNA, who was supposed to assist, was on break and did not check in with the resident upon returning. The resident was observed participating in an activity during this time, and no staff approached her to ask if she needed to use the bathroom, despite her earlier request. The facility's policy emphasizes person-centered care and the importance of honoring resident preferences and needs, including timely assistance with toileting. The resident expressed discomfort and concern about potentially having an accident due to the delay. Interviews with staff revealed confusion about the resident's toileting schedule and a lack of clear communication regarding her care plan, which contributed to the delay in providing necessary assistance for activities of daily living.

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