Failure to Implement and Document Two-Hour Toileting Checks per Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident who required two-hour checks for toileting assistance. Despite the care plan specifying these checks, both the resident and facility documentation confirmed that staff did not consistently perform or document the required checks. The resident reported that staff were not checking on them every two hours as required, and a review of the daily sign-in sheets over a ten-day period showed multiple missing entries, indicating that the checks were not completed as planned. Further review of the resident's records revealed that the individual had diagnoses including type 2 diabetes mellitus, acute kidney failure, and acute respiratory failure, and was frequently incontinent of urine. The resident's cognitive status was intact, as indicated by a BIMS score of 13 out of 15. Interviews with the CNA and DON confirmed that the two-hour checks were required and that documentation was necessary to verify completion. However, both acknowledged that blank sections on the sign-in sheets meant there was no way to confirm if the checks had been performed, directly leading to the deficiency.