Failure to Provide Required Two-Person Assistance During Bed Bath
Penalty
Summary
A deficiency occurred when a resident with paraplegia, severe cognitive impairment, and total dependence for bathing was given a bed bath by only one CNA, despite her care plan and MDS assessment specifying the need for assistance from two staff members. The resident was observed receiving a bed bath from a single CNA, with the resident uncovered and the bath water present, confirming that the care was being provided by only one staff member at that time. Interviews with the CNA involved and other staff confirmed that the resident was known to require two-person assistance due to her physical and behavioral needs, including a history of hitting and kicking during care. Staff interviews revealed inconsistent understanding and practices regarding when two-person assistance was required. Some CNAs relied on the Kardex, care plan, or verbal instructions from nurses to determine the level of assistance needed, while others mentioned that the need for two-person assistance could depend on the resident's behavior at the time. There was also uncertainty about the frequency and content of in-service training related to one- or two-person assists, with some staff recalling recent training and others unsure about when it last occurred. The facility's leadership, including the DON and Administrator, confirmed that the care plan and Kardex should be checked to determine the required level of assistance, and that nurses are responsible for monitoring and communicating changes to CNAs. However, it was noted that there was no specific policy on supervision, use of the Kardex, or CNA responsibilities regarding one- or two-person assists. This lack of clear policy and inconsistent staff practices led to the resident not receiving the required level of supervision and assistance during a bed bath.