Failure to Develop Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
A review of medical records for a resident revealed that the individual was incontinent of both bowel and bladder. Despite this, there was no evidence that a care plan had been developed to address the resident's bowel and bladder incontinence. The Minimum Data Set (MDS) confirmed that the resident was always incontinent of both bowel and bladder, and this condition had been present since admission. Interviews with facility staff indicated that the interdisciplinary team is responsible for reviewing each resident's plan of care quarterly and annually, with the nurse unit manager specifically tasked with ensuring the nursing portion is current. However, upon review, both the surveyor and the nurse unit manager acknowledged that a care plan for incontinence was missing for this resident, confirming the deficiency.