Inaccurate Bowel and Bladder Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a bowel and bladder assessment for one resident, as required by its own policy. The resident in question had a history of metabolic encephalopathy and Alzheimer's Disease, was severely cognitively impaired, bed bound, and dependent on staff for all activities of daily living. Multiple records, including the Minimum Data Set (MDS) and Admission/Re-admission Data Tool, consistently indicated that the resident was always incontinent of both bowel and bladder. However, the Bowel and Bladder Assessment for this resident incorrectly documented that the resident always voided appropriately without incontinence. This discrepancy was identified during interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), both of whom confirmed the assessment was inaccurate and did not reflect the resident's actual condition. The facility's policy required documentation to be objective, complete, and accurate, but this was not followed in the resident's assessment.