Failure to Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with bladder incontinence and an ADL self-care performance deficit, the care plan required incontinence care every two hours and as needed, with total assistance to keep the skin clean and dry. However, during an observation, the resident was found wearing a heavily soiled brief, turn pad, and draw sheet, all soaked with urine and emitting a putrid odor. Both CNAs interviewed confirmed that the care plan was not followed, and the resident had not received peri care as scheduled. The DON also confirmed that leaving a resident unclean and heavily soiled with urine increases the risk of infection and that peri care should be performed every two hours. Another resident with a self-care performance deficit required two staff members to assist with repositioning and turning in bed, as documented in the care plan. Despite this, a CNA repositioned the resident alone at the resident's request, resulting in the mattress sliding and the resident falling onto the floor. The CNA acknowledged that the care plan specified two-person assistance and admitted fault for not seeking help. The resident's medical history included Guillain-Barre Syndrome, paraplegia, restlessness, agitation, lack of coordination, and muscle weakness, and the resident was cognitively intact according to the most recent assessment. The MDS nurse confirmed that care plans are essential for determining and meeting residents' needs and should be followed by all staff.