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F0584
D

Failure to Timely Empty Bedside Commodes and Urinals

Cleburne, Texas Survey Completed on 05-08-2025

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

The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents by not ensuring that bedside commodes and urinals were emptied in a timely manner. For one resident, who was cognitively intact and required supervision or touch assistance for toileting hygiene, observations revealed that her bedside commode contained urine and a brief for several hours after use. The resident reported that it was common for urine to remain in her commode due to staff not making regular rounds, despite staff being present in her room multiple times since her last use. Another resident, also cognitively intact but dependent on staff for toileting hygiene, was found to have a urinal containing urine for several hours. The resident stated that his urinal typically was not emptied until shift change, and observations confirmed the presence of full and partially full urinals throughout the morning and early afternoon. Staff interviews indicated that CNAs were expected to make rounds every two hours to check and empty bedside commodes and urinals, but this was not consistently done due to other duties or lack of awareness. Facility policy required frequent checking and timely emptying of urinals and commodes, especially for residents who preferred to keep these items at their bedside. Both nursing and administrative staff acknowledged that failure to empty these items could result in odors and flies, and confirmed that all nursing staff were responsible for this task. The deficiency was directly observed and confirmed through resident and staff interviews, as well as review of facility policy.

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