Failure to Follow Two-Person Assist Care Plan for Dependent Resident
Penalty
Summary
The facility failed to follow the comprehensive, person-centered care plan for a resident who required a two-person assist for toileting and incontinence care. On the night in question, a CNA provided incontinence care alone, despite the care plan specifying that the resident was dependent on two staff members for bed mobility, turning, repositioning, and toileting. The CNA reported that the resident was combative during care, and the incident was later confirmed by the Nursing Home Administrator (NHA) and Director of Nursing (DON) during their investigation. The care plan, which had been updated and reviewed multiple times, clearly indicated the need for two-person assistance due to the resident's total dependence for activities of daily living (ADLs) and her frequent refusal of care. The resident involved had a complex medical history, including generalized osteoarthritis, dysphagia, COPD, diabetes, anemia, seizures, pressure ulcers, dementia, mood disorders, osteoporosis, neuromuscular dysfunction of the bladder, psychosis, major depressive disorder, anxiety, and hypertension. At the time of the incident, the resident was moderately cognitively impaired, as indicated by a BIMS score of 10, and was observed to be confused and unable to answer questions about her care needs. The facility's policy required that care and services be provided in accordance with the comprehensive assessment and care plan, but this was not followed in this instance.