Failure to Evaluate and Implement Toileting Program for Incontinent Resident
Penalty
Summary
Facility staff failed to evaluate and implement a toileting program for a resident who was frequently incontinent of bowel and bladder. The resident, who had diagnoses including type 2 diabetes mellitus, chronic constipation, benign prostatic hyperplasia, polyuria, and bilateral osteoarthritis of the knee, was assessed as having moderate cognitive impairment but retained awareness of the urge to void and defecate, could find the toilet, understood reminders, and was motivated to be continent. Despite these abilities and the facility's policy requiring appropriate treatment and services for incontinence, the resident was not placed on a toileting program. Record review showed that the resident's last bowel and bladder evaluation was completed in October of the previous year, with no updated assessment since then, even though quarterly evaluations were required and the most recent was overdue. Observations and interviews confirmed that the resident was not on a toileting program, despite being able to request assistance and sometimes remaining continent when helped. Facility leadership acknowledged that the system for triggering bowel and bladder evaluations had failed, resulting in the missed assessment and lack of a toileting program for the resident.