Deficient Bowel/Bladder Tracking and Delayed UTI Assessment
Penalty
Summary
The facility failed to ensure accurate tracking and assessment of bowel and bladder function for three residents, resulting in inconsistent documentation and lack of appropriate care planning. For each of these residents, medical records and MDS assessments showed discrepancies regarding their continence status, with some records indicating continence and others indicating frequent or total incontinence. Despite these changes, there was no evidence that bowel and bladder assessments were completed, nor were interventions implemented to restore or maintain the residents' baseline continence. Additionally, care plans were either missing or did not address the residents' incontinence, and there was no participation in restorative or maintenance programs to support continence. For one resident, the facility failed to timely assess and treat a urinary tract infection (UTI). The resident reported left-sided and lower back pain, which was initially attributed to constipation. After a negative KUB x-ray, there was a five-day delay before a urinary analysis was ordered. Subsequent urine cultures and lab results indicated the presence of bacteria and Escherichia coli, but there was no documentation that the physician or nurse practitioner was notified of these results or that a plan was made following the negative KUB. The delay in assessment and lack of documentation contributed to a delay in appropriate treatment for the UTI. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that bowel and bladder function was not tracked with each episode during the MDS assessment window, and that comprehensive assessments or restorative programs were not in place. The MDS Coordinator acknowledged that documentation was limited to once per shift and that continence status fluctuated, while the DON was unable to account for the lack of documentation and follow-up regarding the UTI. These actions and inactions led to deficiencies in providing appropriate care for residents' bowel and bladder needs and in the timely assessment and treatment of UTIs.