Failure to Implement Scheduled Toileting and Bowel/Bladder Retraining for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at high risk for falls and had a history of falls related to toileting needs. The resident had severe cognitive impairment, was dependent for toilet transfers, and was frequently incontinent. The care plan included scheduled toileting and bowel and bladder retraining, with specific instructions to offer toileting assistance every two hours and as needed. Despite these interventions being documented in the care plan, there was no evidence that the bowel and bladder retraining was consistently implemented or documented. The resident experienced multiple unwitnessed falls while attempting to use the bathroom independently, as documented in progress notes. Staff interviews revealed that some CNAs were unaware the resident was on a bowel and bladder retraining program, and the required task was not properly triggered in the point of care (POC) system for documentation. The Director of Nursing confirmed that the retraining intervention was not correctly implemented in the POC prior to the resident's final fall. The lack of consistent implementation and documentation of the scheduled toileting intervention contributed to the resident continuing to attempt independent toileting, resulting in repeated falls. On one occasion, the resident fell after going to the bathroom independently and sustained an acute left femoral neck fracture, which required hospitalization and surgical repair. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as monitoring and documentation of interventions. However, the failure to implement and document the bowel and bladder retraining as outlined in the care plan led to the resident's continued risk and eventual serious injury.