Failure to Provide Individualized Continence Care and Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in continence and urinary symptoms for a resident diagnosed with Huntington's disease. Upon admission, the resident was continent of bowel and bladder, but began experiencing fluctuating symptoms of incontinence, urgency, and frequency. The facility's continence evaluation assessment lacked detailed information regarding the circumstances and type of incontinence, and did not document interventions or treatments that had previously improved the resident's condition. The assessment inconsistently identified the type of incontinence and omitted a summary, while the resident's risk factors, such as cognitive impairment and use of antipsychotics, were not fully addressed. Documentation revealed that the resident experienced a change in continence status, with multiple episodes of incontinence and urinary urgency noted over several weeks. Despite these changes, the care plan addressing urinary continence was not initiated until several weeks after the initial assessment, and it did not include individualized goals or interventions to prevent further decline or manage urinary symptoms. The care plan focused on activities of daily living and fall prevention, but lacked a comprehensive bladder assessment or a voiding diary to inform an appropriate toileting schedule. Incident reports indicated that toileting was a causal factor in several falls, yet there was no evidence of a thorough assessment to determine the type of incontinence or to develop a tailored toileting program. Interviews with staff revealed a lack of awareness regarding the resident's specific toileting needs, with staff following a standard two-hour toileting schedule for all residents rather than an individualized plan. The resident reported feeling unsupported, stating that staff did not offer regular toileting assistance and that she sometimes attempted to toilet herself, resulting in falls and emotional distress. The facility's incontinence policy required appropriate treatment and services to maintain continence, but the documentation and staff interviews demonstrated that these standards were not met for this resident.