Failure to Document and Provide Required Toileting Hygiene Assistance
Penalty
Summary
A deficiency was identified when the facility failed to provide documented evidence that care and assistance with activities of daily living, specifically toileting hygiene, was provided to a resident who required maximal assistance. The resident, who had diagnoses including paraplegia, spinal stenosis, and diabetes, was assessed as needing substantial and maximal assistance with toileting hygiene and was frequently incontinent. Documentation for two specific dates showed 'NA' (not attempted) for toileting hygiene on both day and evening shifts, and there were no progress notes indicating that incontinence care was provided on those dates. The resident had also filed grievances regarding delays in incontinence care. Interviews with staff revealed inconsistent understanding and use of the 'NA' code in documentation, with one CNA stating that 'NA' was used if the resident did not have a bowel movement, while facility policy indicated 'NA' meant not attempted. The Infection Preventionist confirmed that ADL documentation should be completed every shift to ensure care was given, but could not confirm whether care was provided on the dates in question. The lack of documentation and conflicting explanations from staff led to the finding that the facility did not ensure proper care and assistance for the resident's toileting hygiene needs.