F0677

E

Failure to Provide and Document Incontinence Care for Dependent Residents

South Holland, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document required incontinence and toileting care for multiple residents who were dependent on staff for these activities of daily living (ADLs). Four residents with significant medical conditions and documented dependence on staff for toileting—R1, R3, R4, and R5—had numerous shifts with no recorded assistance with toileting or incontinence care in their Point of Care (POC) Response History. Facility policies required incontinent residents to be checked every two hours and to receive perineal and genital care after each episode, as well as at least daily during routine CNA care, and required staff to document ADL assistance every shift. Despite these requirements, the POC records for each of the four residents showed multiple dates and shifts with no documentation of toileting assistance, and no additional documentation was found to show that care was provided.

R1 had diagnoses including Alzheimer’s disease, severe dementia with behavioral disturbance, malnutrition, chronic kidney disease, adult failure to thrive, and convulsions, and was documented on the MDS and care plan as totally dependent on staff and always incontinent of bowel and bladder. R1’s POC history showed no documented toileting assistance on multiple specified dates and shifts. R3, who had hemiplegia, cataracts, hypertension, type 2 diabetes, and depression, was cognitively intact per MDS and dependent on staff for toileting with frequent incontinence. R3 reported having to wait a long time for help, sometimes not receiving incontinence care, and stated that staffing was inadequate. R3’s POC history also lacked documentation of toileting assistance on numerous dates and shifts, and a cognitively intact roommate (R8) corroborated that roommates needing incontinence care had to wait “forever” for staff assistance.

R4 had diagnoses including rhabdomyolysis, lumbar spine fusion, inflammatory spondylopathy, type 2 diabetes with neuropathy, malnutrition, neuromuscular bladder dysfunction, obesity, COPD, and major depressive disorder, and was cognitively intact but dependent on staff for toileting with frequent incontinence. R4 reported that there was not enough staff, that it could take 3–4 hours to get help, and described being left hanging in a Hoyer lift for over three hours in feces and being left in urine and feces for hours, including at the time of interview. R4’s POC history showed many shifts without documented toileting assistance. R5, with severe dementia, traumatic subdural hemorrhage, osteoporosis, lymphedema, malnutrition, and muscle wasting, was cognitively impaired and dependent on staff for toileting with frequent incontinence; R5’s POC history also showed multiple dates and shifts without documented toileting assistance. The restorative nurse (LPN) responsible for monitoring ADL status and charting confirmed that these residents were dependent on staff for toileting and that many shifts of ADL charting were missing, acknowledging ongoing problems with CNA completion of charting. The DON affirmed that staff are required to document ADL assistance every shift, yet no further documentation was available to show that toileting or incontinence care had been provided to these residents during the identified periods.