Failure to Provide and Document Toileting and Incontinent Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently offered and documented incontinent and toileting care, including refusals, for a dependent resident with bowel and bladder incontinence. The resident had diagnoses including COPD, anxiety, hemiplegia, hemiparesis, abnormal posture, and bilateral osteoarthritis, with intact cognition and a care plan indicating maximal assistance for toileting hygiene using a stand-up lift with two staff. The care plan also included interventions such as application of barrier cream after perineal care, use of disposable briefs, and monitoring for UTIs. The physician orders contained no specific toileting orders. Electronic health record review showed the resident was incontinent daily over a one‑month period with only four continent episodes, and behavior documentation was silent for any refusals or rejection of care. Toileting task documentation showed multiple days where the task was marked as not occurring, and several days where the resident was documented as completing toileting tasks with only supervision, despite the care plan indicating a need for maximal assistance. On the day of surveyor observation, two CNAs offered to take the resident to the toilet, and the resident refused; no further attempts to provide care were observed over the following 2 hours and 15 minutes. The ADON and DON confirmed that toileting documentation for the resident was incomplete, that nurses’ notes lacked detail about what care was refused, and that there was no other documentation showing staff offers of toileting assistance or refusals, despite daily documentation of incontinence without corresponding incontinent care entries. Later that day, the resident was observed wearing jeans with a large wet area from the perineal area to mid‑thighs and reported having been in and out of the facility all day to smoke, stating that staff did not come outside to remind or offer toileting and that she could not transfer herself from the wheelchair to the commode due to left‑sided weakness. Review of the facility’s Activities of Daily Living policy showed that staff were expected to attempt alternative approaches when residents resist care, but this was not followed as written for this resident.
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