Failure to Provide Dignified, Timely Toileting and Respectful Care
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect by providing timely toileting assistance and by using respectful communication. One resident, cognitively intact and dependent on staff for assistance, reported that around 11:00 PM she activated her call light to request help to the bathroom. CNA #1 responded by questioning whether someone had already taken her to the bathroom and, after being informed the resident had been asleep and needed to go at that time, did assist her. Later, at approximately 3:00 AM, the same resident again required toileting assistance. Although CNA #1 assisted her to the toilet, the resident stated she was left sitting there for about 30 minutes without supervision. When CNA #1 did not return, the resident activated the bathroom call light, and upon returning, CNA #1 told her, "I told you I was coming back. I had to make my rounds." The resident reported telling CNA #1 she could not sit on the toilet for that length of time and should not have to remain there for an extended period, and further reported she notified the night nurse, who said the issue would be reported to RN #2. RN #2 later stated she was not made aware of any complaints or concerns about this resident on Monday morning. The DON acknowledged CNA #1 could be gruff in tone, had multiple prior write-ups, including for leaving a resident on the toilet longer than appropriate, and confirmed the expectation that residents receive timely toileting. A second cognitively intact resident with cerebral palsy, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene, was also involved. A family member reported arriving shortly after 1:00 PM and finding the resident’s call light sounding because she was wet and needed to be changed, with three soiled towels from lunch, covered in spaghetti, left on her chest. The family member stated the call light had been going off for some time before day-shift CNA #5 entered the room, removed the soiled towels, and said to the resident, "You're just showing out because your sister is here." CNA #5 later confirmed that dirty towels had been left on the resident’s chest and that the family was upset, and stated she left the room to allow time for the situation to deescalate. The DON confirmed her expectation that all residents have the right to be treated with dignity and respect.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.