Failure to Implement Two-Person Assist for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant cognitive and physical impairments. The resident, an elderly female with diagnoses including dementia, stroke with left hemiplegia, diabetes, epilepsy, and hypertension, was assessed as having severe cognitive impairment and was dependent on two staff members for bathing and transferring, as documented in her care plan and MDS assessments. Despite these documented needs, the care plan contained inconsistencies regarding the level of assistance required for bathing, and interventions were not consistently implemented as specified. On the day of the incident, a CNA provided a shower to the resident alone, despite the care plan indicating a two-person assist and the use of a mechanical lift for transfers. The CNA attempted to transfer the resident from the shower chair to the bed without assistance, during which the resident fell and sustained acute fractures to her right foot and a laceration to her lip. The CNA later stated that due to staffing shortages, she had performed two-person assists alone on several occasions, and acknowledged the risks involved. There was no documentation of any in-service training the CNA claimed to have received following the incident. Interviews with other staff confirmed that the expectation was for two staff to assist with such transfers, and that failure to do so could result in injury. The DON was not present at the time of the incident but reviewed the notes afterward. The facility did not provide a care plan policy when requested. The failure to implement the care plan as written, specifically regarding the required level of assistance for bathing and transferring, directly led to the resident's fall and injuries.