Failure to Follow Two-Person Assistance Care Plan During Toileting
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Staff failed to follow the care plan for a resident with multiple sclerosis and overactive bladder, who was cognitively intact but dependent on others for toilet hygiene. The resident's care plan required two-person assistance for toileting. However, during an incident, an agency CNA provided toileting care alone without a second staff member, contrary to the care plan. As a result, the resident fell out of bed while being assisted. The resident reported that the CNA stated she could provide care without assistance, and facility leadership acknowledged that the care plan was not followed at the time of the fall.