Failure to Support Resident Choice in Incontinence Care
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination and choice regarding incontinence care. The resident, an older adult with a history of hemiplegia, hemiparesis, bipolar disorder, schizoaffective disorder, muscle weakness, and unsteadiness, was frequently incontinent of bowel and bladder and required assistance with activities of daily living. Despite being care planned for frequent checks and changes of briefs as needed, staff insisted that the resident use the commode instead of changing her brief when soiled, even when the resident requested to be changed in bed. The care plan and Kardex indicated the use of briefs and the need for frequent checks, but staff practice was to encourage or require the resident to get up and use the toilet, and if she refused, to delay changing her until she agreed to use the commode or until a later time. Interviews with staff revealed inconsistent understanding and implementation of the resident's care plan. Some CNAs and nurses stated they were instructed by administration to prioritize toileting the resident and to withhold changing her brief in bed if she refused to get up, only returning later to attempt toileting again. Staff described a process where refusal to use the toilet was interpreted as refusal of care, resulting in the resident remaining in a soiled brief until she complied or until staff returned. Documentation and interviews confirmed that the resident was able to request changes when wet but was not always accommodated promptly if she declined to use the commode. The resident herself reported that she could not sense when she needed to urinate, only realizing after she was wet, and that she wanted her brief changed when soiled, but staff told her she had to get up and use the toilet per her care plan. Administrative and clinical leadership interviews further demonstrated a lack of consensus on the resident's continence status and the appropriate response to her requests. The DON and ADM both referenced promoting independence and rehabilitation, with the ADM stating that care should be provided based on need, not want, and that staff should encourage the resident to use the toilet. However, there was acknowledgment that if the resident refused to get up, staff would not immediately change her, and the timing of follow-up was inconsistent. The facility's own policies and in-service education highlighted the importance of resident rights and the distinction between "can't" and "won't" regarding incontinence, but the actual practice did not consistently support the resident's autonomy or timely care as outlined in her care plan.