Failure to Address Bowel Incontinence in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including major depressive disorder, urinary tract infection, neuromuscular dysfunction of the bladder, and paraplegia. The resident was always incontinent of bowel, as documented in the Minimum Data Set (MDS), and required substantial to maximal assistance for transfers and toileting. Despite these documented needs, the resident's care plan did not include any interventions or guidance for managing bowel incontinence, although it did address bladder and catheter care. This omission was confirmed through record review, staff interviews, and direct observation of care. Staff interviews revealed that both the CNAs and the MDS nurse were aware of the resident's bowel incontinence and the need for staff to check and clean the resident. The MDS nurse acknowledged missing the inclusion of bowel incontinence care in the resident's care plan upon readmission. The Director of Nursing also confirmed that the care plan should have addressed bowel incontinence, as the care plan serves as a blueprint for care. The facility's own policy requires that all areas of concern identified during assessment be evaluated and addressed in the care plan, but this was not followed in this case.