Failure to Document Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs). The resident had diagnoses including dementia, hemiplegia, and hemiparesis following a stroke, and was assessed as severely cognitively impaired, totally dependent on staff for toileting and transfers, and frequently incontinent of bladder and always incontinent of bowel. The care plan required staff to provide incontinence care and scheduled toileting or voiding. However, review of CNA documentation from 3/17/25 to 4/7/25 revealed multiple shifts where incontinence care was not documented, specifically on several dates and shifts across the review period. The facility's policy required appropriate treatment and services for residents who are incontinent to maintain bladder function and prevent complications.