Failure to Provide and Document Required Toileting and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to ensure residents who were unable to perform activities of daily living (ADLs) received necessary assistance with toileting and personal hygiene. Documentation and interviews revealed that three residents, all dependent on staff for toileting due to various medical and cognitive conditions, did not consistently receive the required care. Certified nurse aide accountability records showed multiple occasions over a two-month period where toileting was not documented as performed for these residents. One resident, who was cognitively intact but physically dependent, was found by their representative covered in urine and feces on several occasions. Review of care plans indicated the resident required assistance with all ADLs, including toileting, and was frequently incontinent. Certified nurse aide records lacked signatures for toileting on 37 occasions, and staff interviews confirmed that a blank in the documentation meant the task was not completed. Staff cited reasons such as short staffing, lack of time, and sometimes forgetting to document, but also acknowledged that if the box was blank, the care was not provided. Two other residents, both with significant cognitive and physical impairments, also had numerous instances where toileting was not documented as performed. Staff interviews revealed issues with access to electronic documentation systems and occasional computer malfunctions, but staff and nursing leadership confirmed that lack of documentation indicated the task was not completed. The facility's policy required ADL documentation on each shift, and the DON and LPN confirmed that blank documentation boxes meant the care was not provided. These findings were based on record review, staff interviews, and review of facility policies.