Failure to Develop and Implement Comprehensive Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including debility, cardiorespiratory issues, heart failure, diabetes mellitus, and respiratory failure. The resident was dependent on staff for personal care, including toileting hygiene, and was frequently incontinent of urine and always incontinent of bowel. Despite these needs, the care plan did not include specific interventions, tasks, or measurable goals related to toileting hygiene, assistance, or care. Staff interviews confirmed that the resident was not on a toileting program, and the Director of Nursing acknowledged that toileting interventions and steps were missing from the care plan. Observations over several days documented a persistent strong odor of urine in the resident's shared room, and staff reported inconsistent checks for incontinence episodes. Soiled clothing and briefs were found in the room, contributing to the odor. The facility's own policy requires comprehensive care plans with measurable objectives and timeframes to address all identified needs, but this was not followed for the resident in question.