Failure to Follow Care Plan for Dependent Resident
Penalty
Summary
The facility failed to follow the comprehensive care plan for a resident who required extensive assistance with activities of daily living (ADLs) due to diagnoses including diabetes mellitus, hemiplegia, and macular degeneration. The resident's care plan, last revised on 1/2/25, specified that two staff members were required to assist with bed mobility and upper and lower body dressing. However, on 4/29/25, only one CNA assisted the resident with rolling and repositioning, contrary to the care plan instructions. This was confirmed by both the CNA involved and the resident, who reported that only one staff member was present during the incident. Following this event, the resident complained of right arm pain, which was documented in the clinical record and required administration of Tramadol for pain management. The pain was significant, with the resident reporting pain levels of 8 and 6 out of 10 at different times throughout the day. The facility's policy required staff to use the care plan in developing daily care routines, and the DON confirmed that staff are expected to follow the resident's plan of care. The failure to adhere to the care plan resulted in the resident experiencing pain and requiring medication.