Failure to Provide Required Two-Person Assist During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living (ADLs) due to conditions such as functional quadriplegia, contractures, and cognitive impairment, was not provided the required two-person assist during care. The resident's care plan specifically indicated the need for two-person assistance with transfers, repositioning, and daily care due to their high risk for falls and injuries, as well as their inability to participate in or understand care activities. Despite this, a Certified Nursing Assistant (CNA) reported performing the resident's ADL care alone, including cleaning and turning, without assistance from another staff member. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and acknowledged that failing to follow this intervention placed the resident at risk for further injuries. Facility policy emphasized the importance of safety, supervision, and targeted interventions to reduce individual risks, including communicating and assigning responsibility for specific interventions. The failure to provide the required two-person assist as outlined in the care plan and facility policy constituted the deficiency.