Failure to Provide Toileting Assistance and Maintain Call Light Accessibility
Penalty
Summary
A resident with a history of stroke and hemiplegia, who required partial assistance for transfers and was identified as a fall risk, was not provided with necessary toileting assistance. The resident's care plan directed staff to encourage the use of a call light and ensure it was within reach. However, on the morning in question, the resident was found calling out for help and rattling the bed rail, with the call light placed out of reach on the wall. The resident was incontinent of bowel and bladder at that time, despite normally being continent. Staff interviews and clinical record review confirmed that the night shift aide had failed to return the call light to an accessible position after providing care, leaving the resident unable to request assistance. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support, including assistance with elimination. The lack of a room-to-room report between shifts contributed to the oversight, as the day shift CNA discovered the resident's situation upon arrival. The incident was documented in the facility's incident report, and the resident confirmed the event occurred once, with no recall of the staff involved.