Failure to Complete Bowel/Bladder Assessment and Individualized Incontinence Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive bowel and bladder assessment and to develop an individualized urinary incontinence care plan for one resident. The resident had diagnoses including surgical aftercare for a right hip fracture, type 2 diabetes, repeated falls, and dementia, and an admission MDS showing moderate cognitive impairment and frequent urinary incontinence requiring maximum assistance for transfers and toileting hygiene. Although the urinary incontinence care area assessment indicated that urinary incontinence would be addressed in the care plan, the bowel and bladder incontinence assessment left multiple sections blank, including incontinence symptoms, onset and pattern of incontinence, bowel movement pattern, relevant physical factors, cognitive/emotional/communication status, medications affecting incontinence, overflow incontinence, physician order for post-void residual, types of incontinence, and care plan review. The resident’s care plan addressed transfer and toileting assistance but did not include urinary incontinence goals or interventions to maintain or improve continence, and the nursing assistant care sheet contained no bowel and bladder information. Documentation from the review period showed the resident was incontinent of bladder fifty-one times and continent ten times, yet there was no individualized urinary toileting plan on the Kardex or NA care sheet. Observations found the resident in a wheelchair with a call light within reach, wearing an incontinence product and stating he needed staff assistance to use the bathroom and disliked being wet, and that he used the call light for toileting or changing. Interviews with an LPN and multiple NAs revealed that toileting information was expected to be on the Kardex or NA care sheet, but for this resident it did not indicate continence status or a urinary toileting plan; staff instead followed a general practice of offering toileting or checking for incontinence every two to three hours. The DON confirmed that the comprehensive bladder assessment for this resident was incomplete and that the care plan did not address urinary incontinence or include a urinary toileting plan, despite a facility policy requiring a comprehensive bowel and bladder assessment on admission, ongoing reassessment, and use of findings to develop an individualized bowel and bladder program and care plan with specific toileting schedules and related interventions.
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