Failure to Provide Bowel and Bladder Retraining for Incontinent Residents
Penalty
Summary
The facility failed to ensure that three residents who were incontinent of bowel and bladder received appropriate assessments and retraining programs to restore or maintain continence, as required by federal regulations. For one resident, the bowel and bladder assessment was not completed quarterly, and although an initial assessment indicated the resident was a candidate for retraining, there was no evidence of a retraining program being implemented. The resident's care plan and physician orders did not include any interventions for bowel and bladder retraining, and the most recent assessment was incomplete. Another resident did not have a bowel and bladder assessment conducted upon admission, and there was no evidence that the resident participated in a retraining program. The resident's condition changed from frequent incontinence to always incontinent, but no new assessment or retraining program was initiated. The care plan and physician orders for this resident also lacked any mention of bowel and bladder retraining interventions. A third resident was identified as a candidate for prompt toileting based on a completed assessment, but subsequent assessments were incomplete, and the resident was not placed in a bowel and bladder training program. Staff interviews confirmed that the resident should have been included in such a program, and the facility's policy required individualized, resident-centered restorative toileting programs to be care planned and reevaluated at least quarterly. Despite this, there was no evidence that the required assessments and interventions were consistently implemented for these residents.
Plan Of Correction
F690 - Bowel/Bladder Incontinence, Catheter, UTI How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 6/16/25, the Director of Nursing (DON) conducted a bowel and bladder assessment for Resident 3, 10, and 44. The respective residents were offered bowel and bladder training. (Exhibit #16) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the bowel and bladder assessments of the residents. The bowel and bladder training were offered to those residents that qualified for the bowel and bladder program. (Exhibit #17) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Bladder and Bowel Incontinence: A Care Solution," Copyright 2022. (Exhibit #18) - Beginning on 6/17/25, the Minimum Data Set Director (MDSD) will review the bowel and bladder assessment of the residents weekly for three months to identify those residents who are good candidates for bowel and bladder training program. The MDSD will include those residents who are newly admitted to the facility. (Exhibit #19) - Starting on 6/17/25, the MDSD will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The MDSD will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025