Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This deficiency was identified during an abbreviated survey, where it was found that a resident, who was always incontinent and dependent on direct care staff, was diagnosed with urinary tract infections on two separate occasions. The facility's incontinence policy requires residents to be kept dry, clean, and comfortable, with checks and changes every two to four hours. However, documentation revealed numerous instances where direct care staff did not record providing necessary incontinence care over several months. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. Despite having a care plan that included specific interventions to prevent urinary tract infections, such as applying barrier ointment and monitoring for symptoms, the facility's records showed significant lapses in documented care. Interviews with staff indicated a lack of awareness of these documentation omissions, and the Director of Nursing acknowledged that missing documentation could either be an omission or indicate that care was not provided. The deficiency was noted under 10 NYCRR 415.12(d)(1).
Plan Of Correction
Plan of Correction: Approved January 14, 2025 Plan for affected Resident: Resident #1 is being changed every 2-3 hours. Resident is on a UTI prevention protocol. Resident currently has no UTI. Incontinent care documentation is being done following incontinent care for bowel and bladder. Resident currently does not have a foley catheter. Plan to identify other potentially affected residents: Nurse Managers to do daily audits of CNA documentation for incontinent care bowel and bladder of each resident on their unit. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the charting has been done or is in progress for all incontinent residents. Plan for system changes and measures to prevent occurrences: The facility will take the following measure to ensure that the problem does not reoccur: The incontinent policy was reviewed and updated. Nursing Educator to re-educate CNA's and LPN's on peri care, Urinary tract infections and the incontinent policy. All incontinent residents are to be placed on a toileting schedule or changing schedule every 2-4 hours and PRN. Nurse Manager/Supervisor/designee to check that incontinent care is rendered to all incontinent residents on each unit per protocol every 2-4 hours. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the documentation has been done or is in progress after care is rendered for all incontinent residents. Residents readmitted with new foley catheter will be assessed by the RN for appropriateness of the foley and follow up with NP/MD for clinical necessity or foley will be removed if not indicated. Plan for Monitoring Corrective action: Nurse Manager/designee to do weekly audits on 10% of the residents per unit and patient resident observation to ensure that incontinent care is being provided timely and documentation is being done when incontinent care is provided. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).