Failure to Maintain Complete Incontinence Care Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records regarding incontinence care for three residents who required assistance with activities of daily living (ADL). For each resident, the care plans and Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment and dependence on staff for toileting and hygiene, with frequent or occasional incontinence noted. Facility policy required Certified Nursing Assistants (CNAs) to document incontinence care at least every shift, three times daily, including whether the resident was continent or incontinent of bowel and bladder. Record reviews for the previous 30 days revealed multiple shifts where incontinence care documentation was missing for all three residents. Specific dates and shifts were identified for each resident where no documentation was present, despite the expectation for consistent charting. During interviews, the Regional Nurse Consultant confirmed that CNAs were required to document incontinence care every shift and was unable to provide further information regarding the missing documentation. The facility's policy on incontinence management also emphasized the need for documentation following care procedures.