Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
Facility staff failed to develop a care plan addressing bowel incontinence for one resident, despite the resident being assessed as bowel incontinent on the most recent MDS and having diagnoses including diabetes, congestive heart failure, respiratory failure, and peripheral vascular disease. The resident, who was cognitively intact, reported numbness from the waist down and an inability to sense bowel movements, requiring frequent checks by staff. Interviews with a CNA and the MDS coordinator confirmed that the resident was regularly checked for incontinence and that a care plan for bowel incontinence should have been in place but was missed. Review of the clinical record and care plan revealed no documentation of a bowel incontinence care plan for this resident.