Lack of Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease and dysuria, who was frequently incontinent of bladder, did not have a comprehensive care plan addressing her urinary incontinence. The resident's Minimum Data Set (MDS) and Care Area Assessment (CAA) indicated frequent incontinence and a need for assistance with toileting, including transfers and hygiene. Despite these documented needs, the care plan only included an intervention to offer toileting every 2-3 hours and as needed, and to use a brief, without specifying the reasons for incontinence, the type of incontinence, specific goals, or additional interventions. There was also no documentation in the care plan regarding the resident's renal disease or dysuria. Review of the CNA care card showed similar limited instructions, and interviews with the Director of Nursing confirmed that no further interventions or comprehensive planning were in place for the resident's bowel and bladder incontinence. The facility's policy required care plans to include goals and considerations of risks affecting the resident's health, but these elements were missing in this case. No additional information was provided by facility leadership to explain the lack of a comprehensive care plan for the resident's urinary incontinence.