Failure to Provide Timely Toileting Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely toileting assistance to two residents who required staff support for activities of daily living. One resident, who was moderately cognitively impaired and dependent on staff for toileting, was found in the morning with dried bowel movement on her sheets and body, and her brief was stuck to her, indicating she had not been checked or changed during the night as required by her care plan. Staff interviews confirmed that the resident was on a two-hour check and change schedule, but this protocol was not followed during the night shift. Another resident, also moderately cognitively impaired and requiring maximum assistance with toileting, reported that her brief was not changed during the night. She was found in the morning with a saturated brief, incontinent pad, and blanket, necessitating a complete bed change. Staff confirmed that this resident was to be checked and changed every two hours, and documentation and interviews indicated that the required care was not provided during the night shift. Both incidents were corroborated by staff and resident interviews, as well as facility investigations.