Failure to Care Plan for Resident’s Prolonged Bathroom Use and Resulting Conflicts
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan to address one resident’s frequent and prolonged use of a shared bathroom, despite known cognitive impairment and a prior resident-to-resident altercation related to bathroom access. The resident was admitted with diagnoses including unspecified dementia, chronic kidney disease, and other cognitive symptoms, and a BIMS assessment later showed moderate cognitive impairment. A Report of Suspected Dependent Adult/Elder Abuse documented an incident in which the resident’s former roommate blocked the bathroom door while the resident was inside, preventing her from exiting. Staff interviews confirmed that this altercation was related to the resident’s bathroom use and that no care plan had been created to address the underlying issues or prevent recurrence. Multiple residents reported that the cognitively impaired resident used the shared bathroom very frequently and remained inside for extended periods, which delayed their own access and caused them to seek staff assistance or use alternative toileting locations. One resident stated she had to hold her urine and call a nurse to help the resident complete bathroom use so she could enter, while others described the situation as unfair and problematic. Staff, including a CNA and an LN, stated that the resident was forgetful, did not use the call light, removed her personal alarm, and required supervision to prevent prolonged bathroom use, yet there was no care plan addressing these behaviors or the prior altercation. The MDS coordinator and LN confirmed that the resident’s care plans did not include a problem, root cause, or individualized interventions related to bathroom use or resident-to-resident conflict, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments.
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