F0657

D

Failure to Revise Toileting Care Plan After Change in Resident Status

Wilmington, Delaware Survey Completed on 06-06-2025

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to revise a resident’s toileting care plan when the resident’s toileting and transfer status changed. The resident, identified as R44, had quarterly MDS assessments on 12/18/24 and 3/12/25 that both documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact status. On 12/18/24, the clinical record documented that the resident was always incontinent of bowel and bladder and dependent on staff for toileting. By 3/12/25, the clinical record documented that the resident remained always incontinent of bowel and bladder but now required partial to moderate assistance from staff to get on and off the toilet, reflecting a change from dependent to partial/moderate assistance and a promotion of continence. On 6/6/25 at 9:00 AM, record review showed the facility had not reviewed or revised the resident’s toileting care plan to reflect this change in transfer status and toileting approach. During an interview at 10:00 AM on the same day, the Nursing Home Administrator confirmed that the care plan had not been reviewed or revised, and these findings were later discussed with facility and regional leadership at the exit conference.