Failure to Implement Person-Centered Incontinence Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for incontinence care for one resident. The resident's care plan, updated on 4/9/25, specified that the resident should be kept clean and dry, with incontinence/peri-care provided after each incontinent episode and assessments every 2 to 3 hours and as needed. Despite these documented interventions, the resident reported being left in a soiled brief for almost three hours, stating that her requests for assistance were not addressed by staff. She indicated that although staff responded to her call light, they did not return to provide the necessary care. The RN MDS Coordinator confirmed that the care plan was not followed for this resident. The resident, who is always incontinent of both bowel and bladder and is cognitively intact, was admitted with diagnoses including acute kidney failure, heart failure, and depression. Facility policy requires that each resident receive optimal care as defined by their comprehensive assessment and care plan, but this was not adhered to in this instance.