Failure to Document and Provide Assistance with Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide documented evidence that assistance with activities of daily living (ADL), specifically toileting hygiene, was provided for one resident who was dependent on staff for this care. The resident in question was admitted with diagnoses including end stage renal disease, muscle weakness, and type 2 diabetes mellitus, and was assessed as frequently incontinent of bowel and bladder and dependent on staff for toileting hygiene. Review of the resident's ADL documentation revealed multiple shifts across several days where there was no documentation that toileting hygiene was performed. Interviews with CNAs, the MDS Coordinator, and the DON confirmed that the expectation was for staff to document toileting hygiene every shift, and that blank documentation indicated the task was not performed. Further review showed that the resident did not have a care plan addressing incontinence, despite being assessed as dependent and frequently incontinent. The facility's policy required CNAs to assist residents with ADLs and to document care accurately and timely. The lack of documentation and absence of a care plan for incontinence indicated that the required assistance with toileting hygiene may not have been provided as needed for this resident.