Failure to Develop Comprehensive Incontinence Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the urinary incontinence needs of two residents. For one resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living, the care plan lacked specific instructions regarding the frequency of incontinence care. Although staff interviews indicated that incontinence care was generally provided every two hours or as needed, this frequency was not documented in the resident's care plan or on the CNA Kardex. Additionally, documentation of incontinence care provided was inconsistent, with significant gaps in the electronic health record regarding the number and timing of urinations. For another resident with a history of stroke, diabetes, chronic respiratory failure, and moderate cognitive impairment, the care plan also failed to include a person-centered approach to incontinence care. The resident was assessed as always incontinent of urine and bowel and dependent on staff for all care. While the CNA Kardex and staff interviews indicated that incontinence care was provided every two hours or as needed, there was no specific care plan developed to address the resident's incontinence needs, nor was the frequency of care documented in the care plan or Kardex. Interviews with nursing staff and management confirmed that the facility's practice was to provide frequent check and change for incontinent residents, but this was not consistently reflected in the care plans. The lack of measurable objectives and timeframes in the care plans for both residents did not meet the facility's own policy requirements or regulatory expectations for comprehensive, person-centered care planning.