Failure to Implement Individualized Incontinence Management Plan
Penalty
Summary
The facility failed to develop and implement an individualized plan to meet the toileting needs of a resident with severe cognitive impairment, dementia, and chronic kidney disease. Despite the resident's care plan identifying issues such as overactive bladder, frequent urinary and bowel incontinence, hemorrhoid pain, urinary pain, recurrent UTIs, and atrophic vaginitis, the plan did not include a structured toileting schedule or individualized incontinence program. The resident required substantial assistance for bed mobility, transfers, and toileting, and was always incontinent of urine and frequently incontinent of bowel. Documentation showed the resident was not on a toileting program, and the nursing information system lacked instructions for timely toileting or incontinence care. A quarterly toileting review noted a decline in continence and the need for extensive assistance, but did not specify individualized interventions such as scheduled toileting. The resident was documented as being incontinent of urine 100% of the time during every shift, and a family grievance reported the resident was found soaked with urine. The Director of Nursing confirmed there was no documented evidence of a planned incontinence management program for the resident, indicating a failure to provide timely and individualized care as required by facility policy and state regulations.