F0677

D

Failure to Provide Timely Toileting and Hygiene Assistance to a Dependent Resident

Gonzales, Texas Survey Completed on 01-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care to a dependent resident, as required by the resident’s care plan and facility policies. The resident was an adult male with cerebral infarction, quadriplegia, and muscle wasting/atrophy, admitted with total dependence for all ADLs, including toileting hygiene, transfers, and personal hygiene. His MDS and care plan documented that he was cognitively intact (BIMS 14), used a wheelchair, was always incontinent of urine and frequently incontinent of bowel, and required two-person assistance and a mechanical lift for transfers and toileting. The care plan also identified him as at risk for impaired skin integrity and pressure ulcers due to moisture, with goals for intact skin and interventions including assistance with movements/tasks and total dependence for toilet use.

On the day of the incident, the resident reported that he had been wet for about an hour and stated that a CNA did not want to change or bathe him. At 12:48 PM, he was observed in his wheelchair, appropriately dressed, holding his call light, and expressing anger about being left wet. At 12:50 PM, CNA A entered his room in response to the call light, turned it off, told him she was waiting for additional staff to help with his brief change, and left the room quickly without allowing him to fully explain his needs. At 1:06 PM, the resident stated he was still waiting to be changed. CNA A entered again, placed wipes, gloves, and changing pads on the bed, commented that the resident was impatient, and left the room, stating she needed another staff member to assist, but did not provide care at that time.

Subsequent observations showed that CNA A did not secure a second staff member and initiate care until more than 30 minutes after the resident’s request. At 1:19 PM, CNA A was observed asking a Med Tech to assist with a two-person brief change, and at 1:21 PM they entered the room to provide incontinence care, then exited quickly. At 1:24 PM, CNA A wheeled the resident to the shower area, again stating that the resident was impatient and that she needed another staff member to help clean, change, or bathe him. At 1:28 PM, the Med Tech entered the shower area to assist with toileting hygiene and showering. Interviews with CNAs, an LVN, the Regional Nurse Consultant, and the Administrator confirmed facility expectations for call light response (generally within 5–10 minutes), two-hour rounding, and that waiting more than 30 minutes for a brief change was considered excessive and unacceptable. CNA A acknowledged that the resident waited more than 30 minutes for toileting hygiene, that a 40-minute wait was excessive, and that she had difficulty obtaining help from other staff, resulting in the resident remaining soiled for an extended period despite being totally dependent for ADLs.

Facility policies on Resident Rights, ADL support, and the call system required that residents be treated with respect and dignity, receive necessary services to maintain grooming and personal hygiene when unable to perform ADLs independently, and have calls for assistance answered timely. The resident’s documented dependence for toileting and hygiene, combined with his incontinence and risk for skin breakdown, required prompt assistance with elimination and hygiene. Despite these requirements, the resident remained wet for more than 40 minutes after his second verbal request to CNA A, with delays attributed by staff to difficulty obtaining a second person for transfer and care. Staff interviews consistently described that more than 30 minutes for toileting hygiene was outside facility protocol and could be considered neglectful, and leadership confirmed that a wait time exceeding 35 minutes for a total-care, alert resident to have his brief changed was unacceptable. These observations and interviews demonstrate that the facility did not ensure the resident received timely assistance with ADLs necessary to maintain good grooming and personal hygiene as outlined in his care plan and facility policies.