Failure to Provide and Document Required Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was totally dependent on staff for these needs. The resident, who had multiple complex medical conditions including COPD, morbid obesity, pulmonary fibrosis, and congestive heart failure, was admitted and required one-person assistance for toileting. Documentation revealed that required two-hourly toileting and shift-based bowel elimination records were missing for several time periods during the resident's stay. This lack of documentation indicated that the resident may not have been offered or provided toileting assistance as required by facility policy. The Director of Nursing confirmed during an interview that it was the facility's expectation and practice to offer and document toileting every two hours for newly admitted residents, and to document bowel movements once per shift. Upon review, the DON acknowledged the absence of documentation for the specified periods and could not provide any alternative records to demonstrate that the resident received the necessary assistance. The deficiency was identified following a complaint that the resident had been left in a wet brief for an extended period.