| 4543 |
PIONEER HEALTH OF CENTRAL GEORGIA |
115564 |
712 PATTERSON STREET |
BYROMVILLE |
GA |
31007 |
2016-12-10 |
272 |
D |
0 |
1 |
QBL111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record review, and bowel and bladder program policy review, the facility failed to complete a comprehensive assessment for 1 out of 45 sampled residents (R) (R#87.) R#87's assessment for urinary incontinence was not comprehensive. Findings include: Review of the facility's Bowel and Bladder Continence Program policy, dated 2/2016, provided the following information, A resident is screened upon admission for participation in the Bowel and/or Bladder Continence program. Potential factors or underlying causes that may be contributing to bowel and/or bladder incontinence are identified and addressed by the interdisciplinary team. Under Bowel & Bladder Continence Program, it directed the staff to, .3. Initiate the Elimination Pattern for at least 3-5 days to collect information on elimination pattern .6. Complete and review, with the interdisciplinary team, the Bladder Incontinence data Collection/Evaluation within the first 14 days after initial identification of bladder incontinence. After the comprehensive review with the interdisciplinary team, the policy directed to identify appropriate interventions based on the type of incontinence identified. Review of the Admission Record showed R#87 was admitted to the facility on [DATE]; she was [AGE] years old with [DIAGNOSES REDACTED]. Review of the 7/6/16 Admission Minimum Data Set (MDS) assessment showed the resident was severely impaired in decision making and coded as rarely understanding others or being understood by others. The resident was coded as being dependent on staff for many activities of daily living (ADLs), including toilet use. The resident was coded as being always incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 7/11/16, was triggered for in depth assessment due to the resident being always incontinent of urine and being totally dependent on staff. Boxes were checked on the CAA for presence of: [MEDICAL CONDITION], psychological or psychiatric problems, restricted mobility, urinary urgency and need for assistance in toileting, diabetes, depression, [MEDICATION NAME] medication use, sedative hypnotic use, antipsychotic medication use, and antidepressant medication use. The assessment summary documented under care plan considerations, Describe the impact of this problem/need on the resident and your rationale for care plan decision read in full, Resident is disoriented and mumbles incoherently to herself. She receives total care from staff. She will put herself in the floor and will spit. She sits in open areas in chair as tolerated daily. The documentation did not specifically address urinary incontinence. There was a lack of assessment of the resident's diagnoses, medications, cognition, and need for assistance in relation to her incontinence. There was no evidence the resident's voiding patterns had been evaluated to determine the best approach to maximize continence or keep her clean and dry. Under care plan considerations, the overall objective was not identified. Staff interview revealed the resident was able to use the toilet successfully and be continent of urine and bowel some of the time. The resident was capable of identifying the need to void at times and could communicate this to staff. However, the resident was not routinely toileted, wore an incontinence brief, and was observed incontinent of urine during the survey. Cross reference F315: observation on 12/6/16 at 1:13 p.m. CNA AN interview 12/7/16 at 9:57 a.m. A written request was made on 12/7/16 for assessment of the resident's voiding patterns or any type of incontinence assessment for R#87. On 12/9/16 at 2:22 p.m. the DON was interviewed and stated she did not know whether an incontinence assessment had been completed for R#87. The DON stated she would look for an incontinence assessment; an incontinence assessment was not provided as of the survey exit on 12/10/16. There was no evidence the facility completed the Elimination Pattern for at least 3-5 days to collect information on elimination pattern or the Bladder Incontinence Data Collection/Evaluation within the first 14 days after initial identification of bladder incontinence in accordance with facility policy. During an interview on 12/9/16 at approximately 4:30 p.m. the facility's Medical Director stated that residents had certain voiding patterns, and added it was a good idea to look at incontinence on an individualized basis. |
2019-09-01 |