Failure to Implement Bladder Management Program
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. Resident #112, who had intact cognition and required substantial assistance with activities of daily living, was frequently documented as incontinent of bladder. Despite this, the resident's care plan did not include a voiding diary or a toileting program, which are essential components of a bladder management strategy. The facility's policy required assessments and individualized re-training programs for bladder function, but these were not implemented for Resident #112. Interviews with the resident and staff revealed that the resident was not placed on a toileting schedule and was not encouraged to use the bathroom regularly, despite expressing a desire to do so. The resident reported being able to use the bathroom without accidents before entering the facility and expressed dissatisfaction with wearing pullups. Staff interviews indicated a lack of awareness and implementation of an incontinence care plan for the resident, with the Assistant Director of Nursing and a Registered Nurse both unsure why such a plan was not created. A Certified Nurse Aide mentioned that the resident was only put on a toileting program the day before the interview, indicating a delay in addressing the resident's needs.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 690 Bowel/Bladder Incontinence, Catheter, UTI I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident # 112 is now on a toileting program. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by this deficient practice. ? All new admissions will be reviewed for the past three months to ensure appropriate interventions are in place. ? Any identified resident who has a decline in continence of bladder will be placed on toileting program. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the facility policy titled Clinical Bladder Management. ? There were no revisions necessary. ? All nursing staff will receive an in-service education focused on identifying residents who have recently become incontinent with bladder, as well as newly admitted residents who are incontinent with bladder. This in-service education will emphasize the importance of initiating a toileting program aimed at restoring continence to the extent possible. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? The Director of Nursing/Designee will develop an audit tool entitled “Incontinent of Bladder – Toileting Program.” This tool will identify residents who are admitted as being incontinent with bladder, as well as residents who have recently become incontinent with bladder. It will assess whether they were promptly placed in a toileting program immediately, with the aim of restoring the resident’s continence to the extent possible. ? This audit will be conducted weekly for three (3) months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing/Designee. Responsible Person: The Director of Nursing is responsible for ensuring all above is completed.