Failure to Specify Required Staffing for Dependent Resident's ADL Care
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that accurately reflected a resident's need for assistance with activities of daily living (ADLs), specifically the requirement for two staff members to assist with turning in bed, bathing, and changing briefs. The resident, who was readmitted after a hospital stay with multiple diagnoses including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes, was assessed as being severely cognitively impaired and fully dependent on staff for ADLs. The resident's Minimum Data Set (MDS) indicated a need for two or more helpers for these tasks, but the care plan did not specify the number of staff required for assistance. During observation, a CNA was seen changing the resident's brief alone, and the CNA stated she was unaware if two people were needed for the task. The care plan only noted that the resident required extensive to total assistance with ADLs but did not detail the number of helpers needed. The Director of Nursing confirmed that the care plan lacked this critical information, despite the resident's dependency and the facility's policy requiring comprehensive care plans with measurable objectives and timetables based on assessment findings.