Failure to Develop Baseline Care Plan for Bladder Incontinence
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with bladder incontinence. Review of the facility's policy indicated that a baseline care plan should be created to address each resident's immediate health and safety needs within forty-eight hours of admission. However, for a resident with multiple diagnoses including acute kidney failure, personal history of prostate cancer, obstructive and reflux uropathy, and artificial urinary openings, there was no evidence of a baseline care plan addressing bladder incontinence or related preventative measures. Clinical documentation showed that the resident was incontinent and at increased risk for skin breakdown, with recommendations for moisture barrier creams, use of briefs, frequent skin assessments, and pressure relief interventions. Despite these recommendations and a moderate risk score on the Braden scale, the resident's care plan did not include goals or interventions for bladder incontinence or skin breakdown prevention. This deficiency was identified through review of clinical records, facility policy, and staff interviews.