Failure to Address Incontinence in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans addressing individual resident needs as identified in their comprehensive assessments for two of the 28 sampled residents. Specifically, Resident 45, who was admitted with diagnoses including diabetes, heart disease, and hypertension, had a Minimum Data Set (MDS) assessment and Care Area Assessment (CAA) summary indicating that urinary incontinence should be addressed in the care plan. However, there was no evidence of interventions for urinary incontinence in Resident 45's care plan. Similarly, Resident 77, admitted with diagnoses including diabetes, urinary tract infection, and hypertension, also had an MDS CAA summary noting the need to address urinary incontinence, but the care plan lacked corresponding interventions. Additionally, the facility did not implement interventions for bowel incontinence in the care plan of Resident 129, who was admitted with diabetes and hypertension. The MDS indicated that Resident 129 was alert, frequently incontinent of bowel, and required staff assistance for toileting. Despite these needs, the care plan did not include interventions to address bowel incontinence. The Director of Nursing confirmed the absence of documented evidence for interventions addressing urinary or bowel incontinence in the care plans of the mentioned residents.
Plan Of Correction
Part 1. Residents 45 and 77 care plans were updated to include urinary continence. Resident 129 care plan was updated to include bowel incontinence. Part 2. Like residents with urinary or bowel incontinence have been audited to identify any missing care planned interventions. Any change in condition or newly admitted residents will be reviewed daily during clinical meetings. Part 3. Nursing staff education on including appropriate interventions for urinary and bowel incontinence and documenting the interventions in the care plan. Part 4. Residents identified with urinary and bowel incontinence will be audited to ensure appropriate interventions are in place. Auditing will occur weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Audit results will be reviewed at QAPI. Part 5. Date of Compliance is May 13, 2025.