Failure to Complete Bowel and Bladder Assessment on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to complete a required bowel and bladder assessment upon a resident’s readmission, as required by facility policy and professional standards. One resident, admitted in February 2025 with dementia, cerebral infarction, difficulty in walking, and severely impaired cognition (BIMS score of 3), had an earlier Bowel and Bowel assessment that documented bowel continence but listed the bladder section as not applicable. A subsequent quarterly MDS identified that this resident required substantial assistance with toileting hygiene, personal hygiene, and ambulation, used a wheelchair, and was frequently incontinent of both bowel and bladder. The resident’s care plan dated 9/24/25 did not identify the resident’s continence status. After a hospitalization from late November 2025 through 11/27/25, the resident returned to the facility, but review of the clinical record showed no evidence that a Bowel and Bladder Assessment was completed upon readmission. In an interview, the DNS confirmed that, according to the facility’s Urinary Incontinence policy, a urinary assessment should have been completed on admission, readmission, and with any significant change in continence, and acknowledged that such an assessment should have been done following this resident’s readmission. This failure to perform the required assessment upon readmission, despite the resident’s documented incontinence and functional limitations, constituted noncompliance with the facility’s own urinary incontinence policy and professional standards of quality for assessment and care planning.
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