Failure to Document and Provide Necessary Incontinent Care
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide and document incontinent care for a resident who was always incontinent of bowel and bladder. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, traumatic brain injury, anxiety, and major depressive disorder, had an MDS dated 1/16/26 indicating intact cognitive skills for daily decision making and complete incontinence of bowel and bladder. The resident’s family representative reported arriving on 2/4/26 to find the resident in bed with bedding soaked with urine, no incontinent brief or pad in place, and a strong urine odor. This account suggested that necessary incontinence products were not in use at that time. Review of CNA documentation for January and February 2026 showed multiple shifts with no recorded incontinent care for this resident. In January, there was no documentation of incontinent care on multiple specified dates across day, evening, and night shifts, and some entries were marked “N/A.” In February, there was no documentation of incontinent care on several consecutive days on both day and evening shifts. A CNA stated that residents are toileted every two hours and when they request it, but the Director of Nursing and Regional Nurse Consultant confirmed the lack of documentation that this resident received necessary incontinence care.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.