Failure to Provide and Document Required Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document incontinence and toileting care for a dependent, cognitively intact resident. The resident, admitted with multiple diagnoses including Type 2 diabetes mellitus, anemia, paroxysmal atrial fibrillation, legal blindness, gastrointestinal hemorrhage, and adjustment disorder with anxiety, reported many instances where they had a bowel movement and staff did not come in a timely manner to provide needed care. The resident’s Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident was always incontinent of bowel, used a wheelchair, had impaired lower extremity range of motion, and was dependent or required substantial/maximal assistance for toileting hygiene and toilet transfers. Record review of the resident’s bowel elimination task documentation revealed multiple shifts across January, February, and March where no care was marked, despite the resident’s total dependence on staff for toileting. Specifically, there were numerous 7 AM–3 PM, 3 PM–11 PM, and 11 PM–7 AM shifts with no documentation of bowel care provided. The resident’s care plan identified impaired physical mobility and self-care deficit, with interventions stating the resident was totally dependent on staff to meet toileting needs and would be toileted in bed with staff assistance, and also identified constipation related to opioid use, decreased mobility, and fear of pain, with interventions including encouraging the resident to sit on the toilet and following the facility bowel protocol. There were no physician orders specific to incontinence care and no progress notes documenting refusals of incontinence care during the review period. Interviews with nursing leadership and licensed staff confirmed that the facility’s expectation is that CNAs document toileting and incontinence care, including whether a resident voided, and that if care is not documented, it is considered not done. The RN/unit manager, an LPN, and the DON all stated there is no way to verify that toileting or incontinence care occurred if it was not charted. Position descriptions for RNs, LPNs, and CNAs require monitoring and documenting care, reporting changes in condition, and ensuring compliance with care plans and facility policies. The facility’s bowel and bladder/incontinence care policy requires that residents with any incontinence episodes be assisted with toileting or checked for incontinence at specified times (upon rising, before/after meals, activities, therapy, at bedtime, and as needed) and that CNAs document toileting as part of ADL care. Despite these policies and role expectations, the documentation gaps and the resident’s report of delayed care demonstrate that required incontinence and toileting care was not consistently provided or recorded for this resident.
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