Inadequate Urinary Incontinence Management for Residents
Penalty
Summary
The facility failed to comprehensively assess and manage urinary incontinence for two residents, leading to deficiencies in their care. Resident #45, who was admitted with multiple diagnoses including diabetes and heart disease, was noted to be occasionally incontinent of urine. Despite being aware of the need to toilet, the resident was not placed on a toileting program. The bladder assessments for this resident were incomplete, with sections on the type of incontinence and a three-day tracker left blank. The Director of Nursing (DON) confirmed that the resident experienced a decline in urinary function and would have benefited from a toileting program, but the facility lacked a procedure to determine eligibility for such a program. Resident #57, who had severe cognitive impairment and was frequently incontinent of urine, also did not receive a toileting program. The resident's bladder assessments were inaccurate, with a three-day bladder tracker indicating no urination for three days. The assessments failed to identify the type of incontinence or develop a treatment plan to prevent decline or improve bladder function. The DON acknowledged these inaccuracies and the absence of a policy to determine program eligibility, relying instead on the judgment of the nurse completing the assessments. The facility's policies on bowel and bladder assessment and incontinence, as well as the incontinence policy, were not effectively implemented. These policies were intended to ensure residents received appropriate treatment to restore bladder function and prevent infections. However, the facility did not perform adequate incontinence assessments or provide appropriate treatment and services, as evidenced by the incomplete assessments and lack of toileting programs for the affected residents.
Plan Of Correction
The facility failed to ensure to comprehensively assess residents' urinary incontinence to determine the type of bladder incontinence and to develop and implement an appropriate treatment plan to maintain and/or restore the resident's bladder function. This affected Resident #45 and #57. Resident #57 no longer resides in the building. Resident #45's bowel and bladder were evaluated, and a program was started on 3/12/2025 by the Assistant Director of Nursing and Director of Nursing. To identify other potentially affected residents, an audit of residents' bowel and bladder patterns was conducted for all residents, completed on 3/20/2025 by the Assistant Director of Nursing. To prevent reoccurrence, education was conducted for all licensed nursing staff regarding bowel and bladder policy and monitoring, completed on 3/20/2025 by the Director of Nursing. To evaluate the preventative actions taken, audits of bowel and bladder assessments for three residents will be conducted three times a week for four weeks by the Director of Nursing or designee. Audit findings will be reviewed with the QAPI committee weekly for recommendations.