Care Plan Lacked Specificity for Two-Person ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident's care plan was individualized and accurately reflected the resident's need for two-person assistance with activities of daily living (ADLs). The resident, who had diagnoses including quadriplegia and multiple sclerosis, was assessed as being dependent on staff for all ADLs such as eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. The Minimum Data Set (MDS) confirmed the resident's dependency and need for two or more helpers for these activities. Interviews with facility staff, including the Director of Staff Development and a Licensed Vocational Nurse, confirmed that the resident was always assigned two CNAs for mobility and transfers to ensure safety. Despite these assessments and staff practices, the resident's care plan did not specify the requirement for two-person assistance with ADLs. The care plan only generally stated that staff should assist with mobility and ADLs daily, lacking the necessary detail to guide all staff, especially those unfamiliar with the resident. Both the LVN and the Director of Nursing acknowledged during interviews that the care plan should have been more specific and resident-centered, explicitly stating the need for two-person assistance to maintain a safe environment.