Failure to Develop Individualized Toileting Program to Maintain Bladder Continence
Penalty
Summary
The deficiency involves the facility’s failure to provide services to maintain or restore bladder continence for one resident reviewed for bowel and bladder care. The resident was admitted on 3/21/21 and was initially care planned on 8/18/22 as incontinent of urine and unable to cognitively or physically participate in retraining, with interventions limited to assistance with perineal care, monitoring for infection, and providing privacy and comfort. On 1/10/25, a post-voiding diary follow-up assessment documented that the resident was assessed for urinary and fecal incontinence and determined to be a candidate for prompted voiding, but the assessment did not include a toileting plan or any update to the care plan. A quarterly MDS dated 5/15/25 showed the resident had a BIMS score of 15 (cognitively intact), required supervision or minimal assistance for toileting, was occasionally incontinent of urine, and was not on a toileting program. Subsequent CNA documentation from May through September 2025 showed increasing urinary incontinence episodes, with incontinence recorded 9 times out of 111 opportunities in May, 27/117 in June, 29/113 in July, 44/112 in August, and 20/59 in September. An MDS dated 8/14/25 documented a BIMS score of 12 (moderately impaired), supervision or minimal assistance for toileting, frequent urinary incontinence, and no toileting program in place. CNA documentation and task lists lacked evidence of toileting frequency or individualized approaches, and continence records combined urinary and bowel incontinence, making continence status unclear. During interviews, the resident stated she was able to toilet herself and was continent, while a CNA and an LPN reported the resident required assistance with toileting and hygiene, was not on a toileting program, was taken to the toilet every two hours, and had increased incontinence episodes. The facility failed to develop an individualized toileting program despite assessments indicating the resident was a candidate for prompted voiding and documentation of increasing incontinence.
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