F0690

D

Failure to Provide Requested Bedside Urinal to Continent Resident

Fort Belvoir, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide a requested bedside urinal to a continent/occasionally incontinent resident who had a right intertrochanteric femur fracture, repeated falls, and unsteadiness on their feet. The resident’s admission MDS showed intact cognition (BIMS 15/15), partial/moderate assistance needs for toileting hygiene, and substantial/maximal assistance for bed-to-chair and toilet transfers, with occasional bladder incontinence. The resident’s care plan indicated partial/moderate assistance with toilet use and use of incontinent briefs, and that the resident was able to make self-care decisions daily. On multiple observations over several days, surveyors noted that the resident’s urinal was stored in a bag in the bathroom and not at the bedside, despite the resident’s repeated statements that he had requested, but not received, a bedside urinal.

On one observation, when the resident directly asked a CNA for a bedside urinal, the CNA responded that he could not have one at the bedside and must use the call bell to request assistance with using the urinal in the bathroom. In interviews, one CNA stated that bedside urinals were not usually provided due to infection control and that residents were educated to use the call light for assistance, while another CNA stated that if a resident could walk, the urinal would be left in a bag in the bathroom. In contrast, an LPN reported that residents who cannot transfer independently are allowed to have bedside urinals and that staff use them to prevent falls and keep them close so residents do not get up impulsively. The ADON later stated there was no policy regarding bedside urinals and that the resident could have a bedside urinal if able to use it. Throughout the observation period, the resident consistently reported not being provided with the requested bedside urinal.