Failure to Initiate Care Plan for Incontinence Upon Admission
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with multiple diagnoses, including muscle wasting, difficulty walking, and hypertension. Upon admission, assessments documented that the resident was incontinent of both bowel and bladder, with inadequate control and frequent episodes of incontinence. Despite these findings, there was no care plan initiated to address the resident's incontinence, as confirmed by both record review and staff interviews. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the absence of a care plan meant that staff did not have documented goals or interventions to guide care for the resident's incontinence. The facility's policy required a comprehensive care plan to be developed for each resident, including measurable objectives and timetables to address identified needs. The lack of a care plan for incontinence was identified during the survey and was not in accordance with the facility's established procedures.