Failure to Implement Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement the care plan for a resident with multiple complex needs, including diabetes, multiple sclerosis, severe cognitive impairment, and a stage III pressure ulcer. The resident required substantial to maximal assistance with bed mobility, transfers, and activities of daily living, and was dependent on staff for repositioning, dressing, personal hygiene, and eating. Despite care plan interventions specifying frequent repositioning, scheduled check/change for incontinence, and 1:1 assistance with meals, the resident was repeatedly observed lying in bed for extended periods in uncomfortable and improper positions, with the head of the bed at 90 degrees and the resident slumped or with their head bent at an angle. The resident was also observed with exposed skin, uncombed hair, and without staff present to assist with meals, leaving the meal tray untouched and the resident unable to eat due to their position. Staff interviews revealed inconsistent implementation of the care plan, with CNAs indicating confusion or lack of follow-through regarding getting the resident out of bed and providing meal assistance. Documentation showed that after a recent incident where the resident slid out of their wheelchair, staff hesitated to transfer the resident, and therapy had recommended repositioning and returning the resident to bed after meals or when fatigued. However, these recommendations were not consistently followed, as evidenced by multiple observations of the resident remaining in bed, improperly positioned, and without necessary assistance for eating and personal care.