Failure to Assess and Address Bowel and Bladder Continence Needs
Penalty
Summary
The facility failed to assess and provide necessary care and services to maintain or improve bowel and bladder continence for a resident who was always incontinent of bowel and bladder. Despite documentation showing the resident was continent of bowel and had regular urinary frequency upon admission, subsequent quarterly reviews indicated no changes in bowel and bladder status, and the resident was consistently managed with incontinence briefs. Staff interviews revealed that the resident was never tried on a toileting program, and there was no evidence of a bowel and bladder assessment or toileting plan in the resident's records. The resident reported discomfort and difficulty sleeping due to the use of incontinence briefs and expressed willingness to try a toileting plan when asked. The facility was unable to provide a policy regarding bowel and bladder assessments when requested, and staff confirmed that no such assessment process was in place. The care plan interventions focused on managing incontinence with adult incontinence products rather than attempting to maintain or restore continence. Staff relied on the care plan to review bowel and bladder status but did not conduct formal assessments or implement toileting programs, even when the resident indicated awareness of the need to use the bathroom and a willingness to participate in a toileting plan.