Failure to Implement Individualized Incontinence Care
Penalty
Summary
The facility failed to implement individualized approaches to maintain continence for Resident C1, who was admitted with diagnoses of overactive bladder and muscle weakness. The resident's quarterly Minimum Data Set assessment indicated that the resident was always incontinent of bladder and bowel. However, the facility did not identify the type of incontinence or treatment options for the resident in the Elimination Continence Care Screen. Additionally, the resident's care plan for Incontinence Management included an intervention for the resident to be checked and changed at least every hour while awake. Despite this, there was no documentation in the clinical record to confirm that the resident was being checked and changed as outlined in the care plan. The Director of Nursing confirmed the lack of documented evidence that incontinence care was provided to Resident C1.
Plan Of Correction
- C1 no longer resides in facility since 12/15/24. - House audit completed on current residents to determine any additional changes in bowel and bladder. Initial resident centered audits will be conducted with house audit and then quarterly and PRN to determine the effectiveness of each residents person centered plan of care. - Policy entitled, "(Need policy)" reviewed and education provided to all nursing staff. - DON or designee will conduct auditing weekly x 4 then monthly x 2 on resident toileting needs. - Audits will be presented at the monthly QAPI committee for ongoing oversight.