Failure to Update Care Plan for Bowel and Bladder Retraining
Penalty
Summary
The facility failed to ensure that the care plan for a resident with bowel and bladder incontinence was updated to include the offering of a bowel and bladder retraining program, as well as documentation of any refusals to participate in such a program. The resident in question had diagnoses including unspecified dementia with behavioral disturbances, anxiety, and diabetes, and was assessed as moderately cognitively impaired. The Minimum Data Set (MDS) assessment indicated frequent incontinence of both bowel and bladder, while the care plan noted incontinence related to impaired mobility and cognition, with interventions such as two-hour checks and observation of incontinence patterns. The care plan also documented resistance to care, including refusals of weights, medication, and care. Despite these findings, there was no evidence in the clinical record or care plan that the resident was offered a voiding trial or a bowel and bladder retraining program, nor was there documentation of the resident refusing participation in such programs. Interviews with nursing staff confirmed that while the care plan addressed resistance to care, it did not specifically mention offering or refusal of retraining programs. This lack of documentation and action led to the deficiency cited in the report.