Failure to Provide Timely Toileting Assistance Due to Unavailable Lift Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting as part of activities of daily living (ADL) care for one resident. The resident reported to the local health department that on the morning of 10/30/25, they were left on a bedside commode for 2.5 hours before staff responded to transfer them back. Review of the electronic medical record showed that the assigned staff member for that morning, Staff #20, had documented care but there were no entries in the treatment record or progress notes indicating that the resident had been left on the commode or required additional assistance. During a subsequent interview, Staff #20 stated that the resident had been left on the toilet by the previous shift and that staff were unable to transfer the resident off the toilet because the bariatric Hoyer lift required for the resident was not charged. Staff #20 explained that this bariatric lift used a different battery than the other lifts in the facility and staff often failed to plug it in, and that a compatible charged battery could not be obtained from the charger. The DON reported being unsure about the incident and needing to verify the weight limits and usage of the facility’s Hoyer lifts. The NHA stated that the Hoyer lifts in the building had a weight limit of up to 600 pounds and could not explain why this resident required a specific bariatric Hoyer lift, and the surveyor confirmed that the resident did not exceed the weight limit of the other lifts. By the end of the survey, the facility had no additional information clarifying why alternative equipment could not be used to assist the resident off the toilet.
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