Failure to Develop Care Plan for Bladder Incontinence and Resistance to Toileting
Penalty
Summary
The facility failed to develop a care plan addressing bladder incontinence and resistance to toileting for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including vascular dementia and a cognitive communication deficit, was dependent on staff for activities of daily living and required prompting and assistance for toileting. Despite being incontinent of urine and exhibiting resistance to toileting and brief changes, no care plan was in place to address these needs. Multiple staff interviews confirmed the resident's behaviors, such as urinating in inappropriate places and resisting care by refusing to go to the bathroom or stiffening their body during care attempts. Observations included the resident being found in a room with a puddle of urine and staff cleaning up after incontinence episodes. The resident's Durable Power of Attorney and staff members reported ongoing issues with resistance to toileting and incontinence. A review of the electronic medical record confirmed the absence of a care plan for these issues, and facility policy requires a baseline care plan within 48 hours of admission, updated as needed until a comprehensive plan is developed. The Director of Nursing acknowledged that a care plan should have been in place for the resident's bladder incontinence and resistance to toileting.