Failure to Implement Two-Person Assist for Dependent Resident
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with hemiplegia, hemiparesis, kidney failure, and muscle wasting. The resident's care plan, dated 5/6/25, specified a requirement for two-person assistance with transfers, toileting, and bed mobility due to her physical limitations and risk for falls. The resident's MDS assessment also documented total dependence on staff for these activities, indicating that two or more helpers were required. Despite these documented needs, staff consistently transferred and toileted the resident with only one person. Observations confirmed that a CNA transferred the resident from bed to wheelchair and assisted with toileting alone, using a gait belt, while the resident did not assist due to left-sided weakness. Interviews with the CNA and the resident revealed that this one-person assist had been the standard practice since admission, and the CNA was unaware of the care plan's requirement for two-person assistance. The CNA admitted to not reviewing the care plan and relied on training and information from other staff. Further interviews with facility leadership, including the DON, indicated a lack of clarity regarding the resident's required assistance level and a reliance on MDS lookback periods to determine care needs. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these were not followed in practice for this resident, resulting in care that did not align with the resident's assessed needs.