Delayed Assistance with Toileting and Repositioning
Penalty
Summary
A resident with a history of stroke, hemiplegia, hemiparesis, partial digestive tract removal, recurrent urinary tract infections, and vascular dementia required substantial assistance for repositioning and toileting. The resident was cognitively intact and able to communicate needs, as documented in the MDS assessment. On two observed occasions, the resident requested assistance to use the bathroom and experienced significant delays—waiting 36 minutes and 30 minutes, respectively—before being assisted by staff. During the first incident, the resident required a clothing change due to incontinence and expressed feelings of embarrassment and being a burden. The care plan indicated the resident should receive necessary assistance with toileting upon request. Staff interviews revealed that delays occurred because two staff members were required for transfers using a mechanical lift, and one CNA was on break during the incident. The CNA did not seek additional help from other available staff or use the walkie to request assistance, despite this being an available option. The DON stated that the expectation is to respond to resident requests within five minutes and that staff should check on residents' needs before going on break. The resident and family members reported that long waits for assistance were a recurring issue, and the resident was on a waiting list for another facility due to dissatisfaction with care.