Failure to Develop Care Plan for Incontinence and Bedside Rail Use
Penalty
Summary
Facility policy on comprehensive person-centered care plans requires that each resident have a care plan with measurable objectives and timetables based on a thorough analysis of the comprehensive assessment to meet physical, psychosocial, and functional needs. For one resident (R2), who had a medical history including anemia, history of falling, chronic kidney disease, type 2 diabetes mellitus, hypertension, and dementia, the clinical record showed documentation of bowel and bladder incontinence in a nursing note dated April 4, 2026, at 9:10 p.m. The record also contained a bed rail evaluation completed on September 10, 2025, approving bedside rails to promote independence. Despite these documented needs and assessments, review of the resident’s care plan revealed no goals or interventions related to incontinence care or the use of bedside rails. This lack of corresponding care plan goals and interventions for incontinence care and bedside rail use for Resident R2 constituted a failure by the facility to develop and implement a complete, measurable care plan that addressed all identified needs, as required by facility policy and 28 Pa Code 211.12(d)(1)(5) regarding nursing services.
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