Failure to Revise Incontinence Care Plan Based on Accurate Assessment
Penalty
Summary
The facility failed to revise the incontinence care plan for one resident following inaccurate documentation of the resident's continence status. Upon admission, the resident was assessed and documented as having bladder incontinence by a registered nurse, and a care plan was developed instructing staff to apply and change incontinence briefs every two hours and as needed. However, the resident was actually continent and able to use a urinal independently, as confirmed by both the resident and the registered nurse who observed the resident's ability to request and use a urinal without issue. Despite this, the care plan continued to reflect incontinence, and the resident was kept in incontinence briefs, which hindered his ability to use a urinal independently. The Director of Nursing acknowledged that the care plan was not updated to reflect the resident's actual continence status, and that revisions should have been made to ensure appropriate interventions. The facility's policy required ongoing assessment and timely revision of care plans as resident information changed, but this was not followed in this case.