Failure to Follow Care Plans for Bed Positioning and Meal Assistance
Penalty
Summary
Surveyors identified deficiencies in the facility's implementation of comprehensive care plans for multiple residents. One resident with dementia, right leg amputation, and right hand contracture was observed lying in bed with the bed in the highest position, contrary to the care plan directive for the bed to be in the lowest position to prevent falls. Staff confirmed the bed was not positioned as required, and the resident was left unsupervised despite being at risk for falls. Another resident with severe cognitive impairment and multiple diagnoses was also found in bed with the bed in the highest position and loose bed rails, again in violation of the care plan which specified the bed should be in the lowest position for safety. Staff interviews confirmed that the care plan was not followed, and the CNA admitted to forgetting to lower the beds after providing care. A third resident with moderate cognitive impairment, left-sided hemiparesis, and visual impairment was not provided with the required assistance and cueing during meals as outlined in the care plan. Observations showed the resident attempting to eat independently despite being unable to use one hand and having difficulty seeing, resulting in food spillage and the use of hands to eat. The resident reported not receiving help despite requesting it, and staff confirmed that the resident should have been provided with a divided plate and a weighted spoon, as well as one-on-one assistance and verbal cues during meals. The care plan interventions were not consistently implemented, and the resident's needs for setup and assistance were not met. The facility's policy requires that comprehensive, person-centered care plans be developed and implemented for each resident, with staff responsible for carrying out specified interventions. However, observations, interviews, and record reviews revealed that staff failed to follow care plan interventions for bed positioning and meal assistance for three residents. These failures were confirmed by supervisory staff and were not in accordance with the facility's own policies and procedures.