Failure to Reassess and Provide Bowel/Bladder Care
Penalty
Summary
Facility staff failed to reassess a resident's bowel and bladder needs or provide necessary care and services to improve continence. The resident, who was alert, able to make their needs known, and had no memory impairment, was always incontinent of bowel and bladder according to the most recent assessment. The care plan directed staff to assist with toileting at specific times and to keep a urinal within reach, as the resident had previously used a urinal successfully in the hospital and expressed awareness of the need to urinate but was unable to walk to the bathroom. Despite these directives, observations showed the resident lying in bed without a urinal present, and staff interviews confirmed that a urinal was not available in the room. Staff acknowledged that they had not reassessed the resident's continence status or initiated a scheduled toileting program as required. The lack of reassessment and failure to provide assistive devices or scheduled toileting left the resident at risk for unmet care needs and avoidable incontinence.