Failure to Specify Toileting Assistance in Care Plans for Dependent Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, specifically omitting clear documentation regarding the level of assistance required for toileting. Both residents had significant physical and cognitive impairments, including muscle weakness, lack of coordination, dementia, and were assessed as dependent for activities of daily living (ADLs), requiring the assistance of two staff members for toileting. However, their care plans did not specify whether a one or two-person assist was needed for this task, and the electronic reports used by CNAs to guide care either omitted the toileting task or failed to indicate the required level of assistance. Observations and interviews revealed that CNAs relied on these electronic reports to determine the care needs of residents, especially when unfamiliar with them. In these cases, the reports did not provide the necessary information, and staff had to rely on their own experience or consult with charge nurses. The MDS-RN and DON both confirmed that the care plans and electronic reports did not reflect the two-person assist requirement for toileting, despite both residents being bed bound and fully dependent for this activity. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans that include measurable objectives and timeframes based on comprehensive assessments. In these instances, the care plans did not meet this standard, as they failed to include specific instructions for toileting assistance, which was a critical need identified in the residents' assessments.