Failure to Assess and Care Plan for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore or maintain bowel and bladder continence for a resident with diagnoses including Parkinson's disease, bipolar disorder, and major depressive disorder. The resident was identified as having intact cognition, required substantial assistance with mobility and transfers, and was dependent on staff for toileting. Despite frequent urinary incontinence and some episodes of bowel incontinence documented over a 30-day period, there was no evidence that a toileting program had been attempted or that a comprehensive assessment for incontinence had been completed. The resident reported awareness of the need to urinate or have a bowel movement but had to wear an adult incontinence brief at all times due to delays in staff assistance, and indicated that a toileting program had not been offered. Review of facility documentation and interviews with nursing staff and the DNS confirmed that an incontinence assessment should have been completed upon admission or with changes in continence status, and that a care plan and toileting program should have been developed based on the assessment. The care plan did not address the resident's incontinence, and the required assessments were missing from the medical record. Facility policies directed that residents with incontinence should receive thorough assessments and individualized care plans, but these steps were not followed for this resident.