Failure to Assess and Intervene for Resident Continence Needs
Penalty
Summary
Facility staff failed to assess and implement interventions to maintain a resident's continence status. Upon admission, the resident had no history of bowel or bladder incontinence and was assessed as always continent, requiring only partial to moderate assistance for toilet transfers and ambulation. However, after admission, the resident experienced multiple episodes of urinary incontinence, primarily during evening and night shifts. The resident reported having to wait extended periods for staff assistance to use the bathroom, sometimes ringing the call bell early to compensate for delays, but staff did not always respond in time. On some occasions, staff turned off the call bell and did not return, resulting in the resident urinating in bed. The resident sometimes attempted to get up independently but required staff assistance when unable to do so. Clinical record review confirmed the resident's continence status changed after admission, with documented episodes of urinary and one episode of bowel incontinence. Despite these documented incidents, there was no evidence that facility staff evaluated or assessed the resident's incontinence episodes or developed a toileting plan to help maintain continence. Additionally, there was no ability to review call bell log activations to correlate with the timing of incontinence episodes. The deficiency was reviewed with the Nursing Home Administrator and Director of Nursing.