Failure to Provide Timely Toileting and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with toileting care for two residents who required substantial or maximal help with toileting and hygiene. One resident, who had intact cognition and required moderate assistance, was observed to have a bedside commode (BSC) containing a large, formed bowel movement that had not been emptied for several hours despite the resident's requests to staff. Staff interviews confirmed that the BSC should be emptied after each use, but this was not done. The facility's investigation could not substantiate abuse or neglect due to uncertainty about whether the resident had informed staff, but direct observation and resident statements indicated the BSC remained unemptied for an extended period. Another resident, also with intact cognition and requiring substantial assistance, reported waiting one to two hours for care after activating the call light and typically relied on staff to empty their urinals. Observations showed two urinals at the bedside, one full and one half full, which had not been emptied since the morning. Staff interviews confirmed that urinals should be emptied frequently and not left to fill. The facility's policy required individualized care plans and prompt toileting assistance, but these were not followed, resulting in residents' toileting needs not being met in a timely manner.