F0690

D

Failure to Establish Voiding Patterns and Toileting Program for Continent/Incontinent Care

Omaha, Nebraska Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to establish voiding patterns and develop an effective toileting program for a resident who was frequently incontinent of bladder. The resident was admitted with hemiplegia and hemiparesis following a stroke and had an admission MDS showing intact cognition with a BIMS score of 13. The MDS documented that the resident was frequently incontinent and not on a toileting program. The Comprehensive Care Plan included interventions stating the resident required assistance with toilet transfers and toileting hygiene, and specifically listed “establish voiding patterns” and “incontinent: routine check and change on rounds and as required for incontinence” as interventions. The Nursing Admission Data Collection indicated the resident had functional urinary status and that the treatment program included routine check and change and prompted voiding.

Record review of the electronic health record, including scanned documents, progress notes, and forms, revealed no evidence that voiding patterns or a bladder diary had been established for this resident. During observation, staff assisted the resident out of bed and to the toilet, and the resident’s bed pad and brief were noted to be wet with urine. In interviews, the resident reported being aware of the urge to use the restroom, needing to turn on the call light and wait for assistance, and expressed a desire to be on a toileting program to restore continence, which had not been offered. A nurse aide confirmed the resident was not on a toileting program and was toileted only when calling for help. The DON confirmed there was no bladder diary or established voiding patterns in place and acknowledged that the established voiding patterns should have been completed.