Failure to Follow Care Plan Requiring Two Staff for Dependent Resident
Penalty
Summary
A deficiency occurred when care was not provided in accordance with the resident's plan of care for a resident diagnosed with hemiparesis and vascular dementia, who had moderately impaired cognition and required maximal assistance with ADLs. The resident's care plan specified that two staff members were required to provide care due to left-sided weakness and behavioral concerns, and to assist with incontinence. On the day in question, the resident alleged that the call light was on for 45 minutes and that ADL care was not provided in the morning. Documentation and staff interviews confirmed that care was provided by only one nurse aide, despite the care plan's requirement for two staff members to be present during care. Further review revealed that the nurse aide checked the resident for incontinence early in the morning but did not check again for approximately three and a half hours, at which point the resident was found incontinent and care was provided by the aide alone. The aide admitted to providing care without a second staff member, citing experience and unavailability of other aides, and acknowledged that this was not in accordance with the care plan. Interviews with facility leadership confirmed that the resident required two staff for care and that the care plan was not followed during the incident.