Failure to Provide Timely Toileting Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely toileting assistance for two residents who required staff support for activities of daily living. One resident, with diagnoses including hypertension, repeated falls, pain, and kidney stones, was assessed as cognitively intact and required supervision or assistance for toilet transfer and hygiene. The resident's care plan specified the need for staff assistance due to general weakness and a history of falls. The resident reported that staff response to call lights could take up to half an hour, particularly on weekends, resulting in episodes of incontinence while waiting for help. Another resident, also cognitively intact and diagnosed with muscle wasting, lack of coordination, acute kidney failure, and chronic pain syndrome, required substantial assistance for toileting. The care plan directed staff to assist the resident to the restroom every two hours or sooner upon request. This resident reported frequent delays in staff response to call lights, leading to repeated incontinent episodes. Multiple staff members, including CNAs and the Director of Nursing, confirmed that staffing shortages, especially on nights and weekends, contributed to delays in answering call lights and providing timely toileting assistance.