Failure to Provide Resident Opportunity for Toileting
Penalty
Summary
A resident with a history of right femur fracture, muscle wasting, atrophy, and cognitive impairment was re-admitted to the facility and required moderate assistance for transfers. The resident was frequently incontinent of bladder and bowel and had a care plan in place that included a toileting program and interventions to maintain cleanliness and monitor elimination. On the evening in question, video footage showed the resident requesting to use the bathroom, but the assigned CNA did not assist her to the toilet. Instead, the CNA instructed the resident to urinate in her incontinence brief, stating it was difficult for her to use the toilet due to her leg injury and that she would be cleaned up afterward. The CNA later confirmed in an interview that he did not redirect the resident appropriately and opted to have her use the brief because he was about to change her. The care plan interventions, which included providing opportunities for toileting, were not followed, and the resident was not given the chance to maintain her ability to perform activities of daily living related to toileting. This incident was identified through record review, policy review, video evidence, and staff interviews, and it affected one resident out of four reviewed for change in condition.