Failure to Document Toileting Hygiene for Dependent Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of Activities of Daily Living (ADLs), specifically regarding toileting hygiene, for four sampled residents. Interviews and record reviews revealed that aide staff did not consistently document incontinence care or toileting hygiene every day and every shift as required. The Director of Nursing (DON) confirmed that documentation was missing and that aides were expected to record perineal hygiene under toileting hygiene for each shift. The residents involved had significant medical histories and were all dependent on staff for toileting hygiene. One resident had multiple diagnoses including osteoarthritis, dementia, and neuromuscular dysfunction of the bladder, and was described as poorly motivated and frequently refusing care. Another resident had quadriplegia and required total assistance for all ADLs. Additional residents had conditions such as COPD, heart failure, traumatic brain injury, and developmental disorders, all necessitating full staff support for toileting and hygiene. Review of the toileting hygiene documentation for these residents showed inconsistent entries, with some days missing documentation of care provided. The DON verified during interviews that documentation was lacking for several residents and that aides should have been documenting perineal hygiene at least every shift. The facility was unable to provide a policy outlining documentation expectations when requested.