Failure to Provide Timely Toileting and Incontinence Care for Cognitively Intact Resident
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to assist Resident #79 in achieving and maintaining bowel and bladder control and dignity in toileting and incontinence care. Resident #79, who had a history of stroke with right-sided weakness, GI bleed, and COPD, was cognitively intact per a BIMS score of 15/15 and had a care plan identifying ADL self-care deficits with goals to improve function. The care plan interventions included use of a mechanical sit-to-stand lift with two staff for transfers and two-person assist for toileting, as well as support for bathing and dressing. Despite this, the resident reported that night-shift CNAs routinely provided a bed bath, dressed her, and transferred her to a wheelchair at 5:30 AM, and that she was not offered toileting every 2–3 hours as she had been told was the expectation by licensed nursing staff. Resident #79 stated she was aware of her need to toilet but had to wait extended periods for assistance because staff required use of a Hoyer lift, which needed two CNAs. She reported that when she used the call light, staff would respond, state they needed to get help, and then not return for hours, often not until after lunch, resulting in her frequently urinating in her brief and having to strain to have bowel movements while waiting. She further stated she did not receive any bowel or bladder care from 5:30 AM until after lunch, and that when incontinence care was finally provided, her brief was extremely saturated. The Ombudsman confirmed frequent complaints from the resident about incontinence care, bathing, toileting, and repositioning. CNA #4 acknowledged checking on the resident but not providing incontinence care until after lunch and stated the resident was not toileted because she used a Hoyer lift, and that she had never seen a special Hoyer pad for toileting or showers. During the final interview, facility leadership claimed such a special Hoyer pad and less-restrictive transfer interventions existed for the resident, but they were unable to provide any documentation or evidence of these interventions.
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