Run Scheduled Toileting Program Compliance Log — Free

Inspection Details

Resident identified and toileting program order verified critical (required)

Confirm the resident is the correct individual and that the scheduled toileting program is active in the care plan or order set.

Yes No N/A

Inspection date and shift recorded

Record the date and time of the compliance check.

Inspector name and role recorded

Document the staff member completing the inspection.

Program type documented

Identify the continence improvement program being audited.

Scheduled Round Compliance

Toileting round completed at scheduled interval critical (required)

Verify the resident was offered toileting at the ordered interval, such as hourly or per care plan.

Yes No N/A

Round time documented accurately

Check that the actual time of the toileting offer or assistance is recorded clearly and legibly.

Yes No N/A

Resident response documented

Record the resident's response to the toileting offer.

Missed opportunity escalated and documented critical (required)

If a round was missed, late, or declined repeatedly, verify escalation to the nurse and documentation in the chart.

Yes No N/A

Pattern of refusals reviewed for intervention

Confirm repeated refusals are being trended and addressed with care plan interventions.

Yes No N/A

Resident Safety and Dignity

Privacy maintained during toileting assistance critical (required)

Verify privacy measures were used, such as closing the door or curtain and limiting unnecessary exposure.

Yes No N/A

Safe transfer or ambulation assistance provided as needed critical (required)

Confirm assistance matched the resident's mobility status and fall risk precautions.

Yes No N/A

PPE used appropriately for hygiene and infection prevention

Check that gloves and other PPE were used according to task and exposure risk.

Yes No N/A

Call light, bedside items, and resident comfort restored after care

Verify the resident was left in a safe, comfortable, and accessible condition after toileting care.

Yes No N/A

Skin integrity concerns observed or reported

Note any redness, moisture-associated skin damage, or other skin concerns related to incontinence.

Yes No N/A

Documentation Quality

Charting is complete, legible, and timely

Verify documentation was entered promptly and can be read and understood by other caregivers.

Yes No N/A

Assistance level documented

Confirm the record shows the level of assistance provided, such as independent, standby, one assist, or two assist.

Yes No N/A

Incontinence episode, if present, documented accurately

If the resident was incontinent, verify the episode, care provided, and any supplies used were documented.

Yes No N/A

Care plan or restorative notes updated when needed

Confirm changes in continence status, refusals, or new barriers were communicated for care plan review.

Yes No N/A

Corrective Action and Sign-Off

Deficiencies documented with corrective action critical (required)

Summarize any non-conformance, missed round, refusal trend, or documentation gap and the corrective action taken.

Follow-up owner assigned

Identify the staff role responsible for follow-up, such as charge nurse, restorative nurse, or CNA supervisor.

Follow-up due date recorded

Enter the date and time by which corrective action or recheck should be completed.

Inspector signature

Signature confirming the inspection findings and documentation review.

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Run: Scheduled Toileting Program Compliance Log

Inspection Details

Scheduled Round Compliance

Resident Safety and Dignity

Documentation Quality

Corrective Action and Sign-Off

Get your results