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F0677
D

Failure to Provide Required Toileting Assistance for Dependent Resident

Kalamazoo, Michigan Survey Completed on 05-14-2025

Penalty

No penalty information released
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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 certified nursing assistant (CNA) failed to provide appropriate assistance with toileting for a resident who required a two-person assist and use of a sit-to-stand device for transfers. The resident, who had difficulty walking, pain in the left foot, and moderate cognitive impairment, requested to use the restroom prior to receiving intravenous medication. The assigned CNA, who was new and inexperienced, expressed discomfort with using transfer equipment and did not seek assistance from other staff members as instructed. Instead of assisting the resident to the restroom or obtaining help, the CNA told the resident to urinate in her brief and stated she would return to clean her afterward. The resident did not want to urinate in her brief and wanted to be transferred to the toilet. The CNA admitted to being uncomfortable with the transfer process and did not attempt to use alternative methods, such as a bedpan, nor did she ask for help from other staff. The incident was reported by an LPN who was present to administer medication and was informed by the resident of the CNA's actions. Interviews with staff revealed that the CNA was aware of how to review the resident's care plan and kardex, which specified the required assistance, but hesitated to provide certain care due to lack of confidence and fear of causing harm. The CNA confirmed her actions and acknowledged not following the resident's care plan or seeking assistance, resulting in a failure to provide necessary ADL support for toileting.

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