Failure to Follow Two-Person Assist Care Plan for Resident Transfers and Toileting
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required the use of ankle-foot orthoses (AFOs) and a two-person assist for transfers and toileting. The care plan specifically stated that two staff members were needed to assist with all transfers and toileting, using a Sara Steady device and providing extensive assistance. However, during observation, only one CNA was present and assisted the resident out of bed and to the toilet. The CNA used improper technique by pulling the resident by the wrists and allowing the resident to lower themselves onto the toilet without assistance. Further, the CNA left the resident unattended on the toilet while leaving the room to make the bed, despite the care plan's requirement for two-person assistance. Interviews with the Director of Nursing and another CNA confirmed that the resident was always to be assisted by two staff members for transfers and toileting. The facility's policy on safe patient movement and handling also emphasized the responsibility of staff to ensure patient safety during handling activities. These actions and inactions resulted in the care plan not being implemented as required for the resident's basic care needs.