Failure to Complete Required Bowel and Bladder Assessments
Penalty
Summary
The facility failed to perform a quarterly bowel and bladder assessment for a resident as required by the resident's care plan. The care plan specified that assessments should be completed on admission, quarterly, and as needed, but documentation showed that the last assessment was performed on 2/14/2025, with no subsequent assessments recorded. This omission was confirmed during interviews with both a registered nurse and the Director of Nursing, who acknowledged that the quarterly assessment had not been completed as required. The resident involved had multiple medical diagnoses, including congestive heart failure, cirrhosis of the liver, reduced mobility, and adult failure to thrive. The resident was cognitively intact, able to make needs known, and required substantial assistance with toileting hygiene. The resident was frequently incontinent of both bowel and bladder, and the care plan included a goal to prevent complications from incontinence, such as skin breakdown or infection. Despite these needs, the required ongoing assessments to monitor and manage the resident's continence status were not performed according to the care plan schedule. Facility policy and procedure documents indicated that comprehensive, person-centered care plans should be developed and implemented for each resident, including measurable objectives and timeframes. The policies also required ongoing assessment and management of urinary continence and incontinence, with regular documentation and review. The failure to follow these policies and the resident's care plan resulted in a deficiency related to the lack of timely bowel and bladder assessments.