Failure to Provide Two-Person Assist for Dependent Resident's Incontinence and Bed Mobility Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia with agitation, generalized anxiety disorder, and major depressive disorder, who was assessed as cognitively severely impaired and totally dependent for toileting hygiene and bed mobility, did not receive care as outlined in their comprehensive care plan. The care plan, as well as the Certified Nurse Assistant Assignments Summary, specified that the resident required the assistance of two or more staff members for incontinent care and bed mobility due to their total dependence and risk for skin breakdown. However, during an observed episode of incontinence care, a single Certified Nurse Aide provided all care and repositioning without the required second staff member, despite the resident intermittently vocalizing during the process. Interviews with multiple staff members, including the CNA involved, another CNA, an LPN, an RN, the Director of Nursing, and the Administrator, confirmed that the expectation and documented plan of care was for two-person assistance for this resident's incontinent care and bed mobility. The CNA acknowledged not following the care plan and not requesting assistance, while all other staff interviewed stated they would have expected the care plan to be followed for the resident's safety. The facility's policy required comprehensive, person-centered care plans to be implemented as written, but this was not adhered to in this instance.