Failure to Individualize Incontinence and Catheter Care
Penalty
Summary
The facility failed to develop and implement an individualized plan to meet the toileting needs of a resident who returned from an acute care stay with an indwelling catheter. Upon readmission, there was no documentation justifying the continued use of the catheter, despite facility policy requiring evaluation of catheter necessity. The resident, who was cognitively intact and required staff assistance for toileting and transfers, had previously been incontinent without a catheter prior to hospitalization. After the catheter was removed, the resident experienced consistent episodes of incontinence, particularly at 9:00 PM over several days, as documented in the voiding pattern record. The resident developed Moisture Associated Skin Damage (MASD) and Incontinence Associated Dermatitis upon return from the hospital. Although the care plan was revised to address frequent incontinence and included general interventions such as two-hourly incontinence checks, cleansing, and barrier cream, it did not specify the type of incontinence, include a structured toileting schedule, or incorporate individualized interventions based on the resident's documented voiding patterns. There was no evidence that the facility evaluated or implemented a plan tailored to the resident's specific toileting needs, and this was confirmed by facility leadership during an interview.