Failure to Provide Consistent Toileting Assistance for Residents
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living, specifically toileting assistance, for two residents. One resident, admitted with peripheral vascular disease and chronic obstructive pulmonary disease, required assistance with ambulation and toileting due to recent arterial bypass surgery and significant pain. Despite care plans and assessments indicating the need for staff assistance with toileting and incontinence care, documentation showed inconsistent provision of these services. The resident reported being left in feces and urine for hours at night, and records indicated that toileting assistance was documented only once per day on several occasions, rather than at least once per shift as expected. Another resident, with diagnoses including heart failure and decreased mobility, also required hands-on assistance with toileting. Over a 29-day period, documentation revealed that toileting assistance was provided only 56 times across 87 shifts, with some days showing only one instance of assistance or none at all. The resident confirmed delays in staff response to call bells, sometimes waiting 30-40 minutes or not receiving assistance at all. Care plans for both residents included interventions for toileting and incontinence care, but the documented care did not align with these plans. Interviews with staff, including the Medical Records manager and the DON, confirmed the lack of consistent documentation and provision of toileting assistance. The DON acknowledged that records reflected toileting assistance being provided only once per day for one resident. These findings demonstrate a failure to ensure that residents received timely and adequate assistance with toileting and incontinence care as required by their care plans and clinical needs.