Failure to Assess and Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to assess and provide appropriate treatment and services for urinary incontinence for one resident. According to the facility's Continence Management policy, residents are to be assessed for continence needs upon admission, and individualized interventions and care plans are to be developed based on these assessments. However, clinical record review showed that a resident admitted with diagnoses including encephalopathy and weakness, who was frequently incontinent of bowel and bladder, did not have a urinary incontinence assessment completed upon admission. The resident was documented as being incontinent of urine and using adult briefs, but there was no evidence of a completed assessment or a care plan with specific interventions to address or attempt to restore bladder continence. Additionally, the Minimum Data Set assessment indicated that the resident's urinary incontinence was to be addressed in the care plan, but no such plan was found in the records. Staff interviews confirmed that neither a urinary incontinence assessment nor care planned interventions had been completed or implemented for this resident, which was not in accordance with facility policy.