Failure to Follow Two-Person Assist Care Plan During ADL Care
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan, which required a two-person assist for all activities of daily living (ADLs) and transfers. The resident, who was bedbound and dependent on staff for all ADLs due to multiple diagnoses including ataxia, muscle wasting, contractures, and aphasia, was found to be always incontinent and required total care. The care plan and signage above the resident's bed clearly indicated the need for two-person assistance. Despite this, a CNA provided incontinent care alone after not finding another available aide. While changing the resident, the CNA attempted to turn the resident without assistance, resulting in the resident rolling off the bed and falling to the floor. The incident was confirmed by nurse's notes and interviews with supervisory staff, who acknowledged that the CNA was aware of the two-person assist requirement but did not follow the established care plan.