Failure to Care Plan for Bowel Incontinence in Resident with Paraplegia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing bowel incontinence for a resident with paraplegia, cognitive communication deficit, and anoxic brain injury. The resident was documented as always incontinent of bowel function in both the Minimum Data Set (MDS) and daily bowel movement records. Despite this, the resident's care plan did not include interventions or goals related to bowel incontinence. The resident reported being unaware of incontinence episodes and stated that incontinence checks were not performed between morning and evening care, resulting in long periods without assessment or care. Interviews with facility staff, including the Unit Manager RN and the Director of Nursing (DON), confirmed that the resident was not care planned for bowel incontinence, despite chronic incontinence being documented. The DON acknowledged that residents with chronic incontinence should have a care plan addressing this need. The lack of a care plan for bowel incontinence was identified through record review and staff interviews, highlighting a failure to meet regulatory requirements for comprehensive care planning.