Failure to Assess and Manage Incontinence
Penalty
Summary
The facility failed to adequately assess and manage bladder and bowel incontinence for three residents, leading to a deficiency in care. Resident 45, who was admitted with conditions including diabetes and hypertension, was identified as a candidate for a scheduled toileting program. However, despite the assessment, the resident was not placed on such a program, and the type of urinary incontinence was not identified in the care plan. There was no documented evidence of a scheduled toileting program being implemented for this resident. Similarly, Resident 77, admitted with diabetes and a urinary tract infection, was frequently incontinent of urine and bowel but was not on a toileting program. The facility did not identify the type of incontinence or develop specific interventions to address it. Resident 129, with diagnoses including diabetes and kidney failure, experienced a change in bowel incontinence status from frequently to always incontinent, yet there was no documentation of an assessment or implementation of a toileting program. The Director of Nursing confirmed the lack of documentation and evaluation for these residents.
Plan Of Correction
Part 1. Resident 45 and 77 types of urinary incontinence were identified and interventions were put into place immediately. Resident 129 change of condition bowel incontinence frequency was identified and interventions were put into place immediately. Part 2. Residents who were admitted or re-admitted to the facility within the last 30 days were reviewed for continence management for incontinence assessment completion. If identified as not having an incontinence assessment in place, it was completed and scheduled as per policy and procedure. Part 3. Nursing education completed to complete fecal and urinary incontinence assessments upon admission/re-admission, change of condition, quarterly and annually. Part 4. To prevent recurrence, the facility will audit new admissions, re-admissions and those due for quarterly assessments to ensure incontinence assessments are completed. Auditing will be completed weekly X 4 weeks, bi-weekly X 4 weeks and monthly X 1 month. Results will be reviewed monthly at QAPI. Part 5. Date of compliance is May 13, 2025.