Failure to Document Two-Person Assist for Dependent Resident in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to document necessary interventions to prevent falls and injuries for a resident with multiple medical conditions, including a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. The resident was assessed as having mild cognitive impairment and was dependent on nursing staff for toileting hygiene and for rolling to either side while lying in bed, requiring a two-person assist for these activities. Despite this, the care plans reviewed did not specify the resident's dependency or the need for two-person assistance for turning and repositioning. The care plans in place addressed impaired physical mobility and risk for falls, listing general interventions such as allowing adequate response time, assessing toileting needs, and encouraging use of the call light. However, they lacked documentation of the resident's specific need for two-person assistance during turning and repositioning. The MDS Nurse confirmed that this level of dependency was identified during assessment but was not included in the care plan, as she assumed that CNAs would understand the implications of the term "dependent" without explicit instructions.