Failure to Include Incontinence Care in Resident Care Plans Upon Admission
Penalty
Summary
Multiple residents were admitted to the facility with documented needs for incontinence care, including total dependence for personal hygiene, toileting, and bathing, as well as episodes of bowel and bladder incontinence. Despite these documented needs, reviews of the residents' admission interim care plans and clinical records revealed that their care plans did not include any goals or interventions specifically addressing incontinence care. This omission was noted for several residents who required substantial or maximal assistance with toileting hygiene or were fully dependent on staff for these activities. The facility's policy on comprehensive person-centered care plans requires ongoing assessments and revisions as resident conditions change. However, the care plans for these residents did not reflect their incontinence care needs, as there was no evidence of appropriate interventions or goals documented. These findings were confirmed in an interview with the Nursing Home Administrator and Director of Nursing.