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F0550
D

Failure to Ensure Dignity and Timely Assistance for Resident Needing Restroom Support

Elizabethtown, Pennsylvania Survey Completed on 05-22-2025

Penalty

Fine: $21,519
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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 was identified when a resident with diagnoses of heart failure and chronic kidney disease, who was documented as being continent of bladder upon admission, experienced several episodes of incontinence due to long call bell wait times. The resident reported feeling embarrassed after not receiving timely assistance to use the bed pan, particularly when she first arrived at the facility. This was corroborated by the facility's Resident Council Meeting Minutes, which documented concerns about long call bell response times. Further review of the resident's clinical record showed that she was marked as incontinent for three consecutive days, despite her admission assessment indicating continence. The DON confirmed that staff reported the resident frequently rang the call bell for restroom assistance, but this was not accurately reflected in the clinical documentation. The DON also stated that staff are expected to document each episode of continence or incontinence, which was not done in this case.

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