Failure to Provide Timely Toileting Assistance and Documentation
Penalty
Summary
A resident with moderate cognitive impairment, a history of cerebrovascular accident, hemiplegia, and diabetes mellitus, was left on a bed pan for five hours without access to a call light. The resident was totally dependent on staff for toilet transfers and hygiene. During this period, the resident experienced significant pain and distress, and no staff checked on her throughout the night. The resident eventually located a call light in a drawer and used it to summon assistance. The incident was not documented in the resident's electronic health record, and there were no assessments recorded regarding the resident's cognitive or physical condition following the event. The Director of Nursing confirmed awareness of the incident and acknowledged the lack of documentation and assessment in the health record.