Failure to Update Care Plan for Urinary Incontinence Preferences
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect a resident's current needs and preferences regarding urinary incontinence care. According to the facility's policy, care plans should be periodically reviewed and updated by a team of qualified persons as the resident's condition changes or based on clinical judgment and resident needs. Record review showed that the resident, who has benign prostatic hyperplasia with lower urinary tract symptoms and intact cognition, expressed concerns that staff did not assist him regularly with urinary incontinence care during the evening and night. He specifically requested assistance at least every 3-4 hours and as needed. Documentation for the resident indicated check and change times at 11:00 p.m., 2:00 a.m., and 4:00 a.m., but the current care plan only stated that staff should provide extensive assist with incontinence care upon demand, not disturb at night, and change at night upon request. The care plan did not reflect the resident's stated preferences for urinary incontinence care. Two administrative nurses confirmed that staff failed to update and individualize the care plan to address the resident's current needs and preferences.