Failure to Specify Staff Assistance Levels in ADL Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that clearly identified the required level of staff assistance for activities of daily living (ADLs) for five out of six sampled residents. Medical record and MDS assessment reviews showed that these residents had significant dependencies, including needs for assistance with toileting, personal hygiene, and transfers from bed to chair. However, their care plans did not specify whether one or more staff members were required to assist with each ADL. Interviews with the DON and CNAs confirmed that the care plans lacked this critical information, making it unclear for staff to determine the appropriate level of assistance needed for each resident. The residents involved had complex medical histories, including diagnoses such as dementia, psychosis, hypertensive heart disease, diabetes, pressure ulcers, Alzheimer's, osteoporosis, hypoglycemia, and schizoaffective disorder. Despite regular MDS assessments and weekly meetings to review residents' assistance needs, the facility did not incorporate this information into the care plans. Staff interviews further confirmed that there was no additional assessment tool in use to determine the specific number of staff required for each ADL, and the care plans remained incomplete in this regard.