Failure to Implement Care-Planned Toileting Schedule for Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned toileting schedule for a resident identified as being at risk for falls. The resident was re-admitted with diagnoses including difficulty walking, muscle weakness, and respiratory failure with hypoxia. Following a fall on 3/12/26, an IDT post-accident/fall review documented that the resident was found on the floor near the bathroom door after a family member called a nurse. The IDT documented existing and new interventions, including placing the bed in the lowest position with the call light and personal items within reach, using a bed alarm, frequent rounding, and initiating a toileting schedule to reduce unassisted ambulation to the bathroom. The resident’s fall care plan, initiated on 3/10/26, identified the resident as at risk for falls related to generalized weakness and specified a toileting schedule to reduce unassisted ambulation to the bathroom, with a start date of 3/16/26. A bowel/bladder incontinence care plan initiated on 3/13/26 also included a toileting program to establish voiding/bowel patterns. Review of the resident’s EMR CNA task list showed a toileting program task directing staff to assist with toileting before and after meals as tolerated and PRN, but documentation of this task was only present on 3/18/26 and 3/19/26. The DON confirmed that the check marks indicated toileting was provided only on those two days and that there was no documentation of a toileting schedule following the fall incident. CNA 1, who was regularly assigned to the resident, reported that the resident had episodes of getting up unassisted specifically to go to the bathroom. CNA 4, assigned to the resident on the 2 p.m. to 10 p.m. shift, stated the resident was not on a toileting schedule and instead woke up whenever he needed to use the bathroom. The facility’s policy on comprehensive, person-centered care plans requires the IDT, with the resident and representative, to develop and implement a care plan that describes the services to be furnished, but the care-planned toileting schedule was not implemented as written for this resident.
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