Failure to Implement Scheduled Toileting and Care Plan Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement a comprehensive, person-centered care plan for a resident with diagnoses including aspiration pneumonia, progressive hyperphagia, and dysphagia. The resident required substantial to maximal assistance with toileting and was on a scheduled toileting program, as documented in the care plan and facility policies. Despite these documented interventions, surveillance video and staff interviews revealed that after lunch, the resident was left unattended in the dining room from 12:10 PM to 3:15 PM without being checked or provided with incontinence care as required every two hours. Documentation did not reflect that the resident was toileted or checked during this period, contrary to the care plan and physician orders. Staff interviews confirmed that the resident was last assisted with toileting around 11:45 AM and was not provided further care after lunch, as staff were occupied with other duties or residents. The resident was eventually found unresponsive at 3:15 PM, and there was no evidence that the required two-hourly checks and changes were performed between 12:10 PM and 3:15 PM. This failure to follow the care plan and facility policy resulted in the resident remaining in soiled conditions for an extended period, as observed and documented by surveyors.