Failure to Follow Care Plan for Dependent Resident During Perineal Care
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was observed for activities of daily living (ADL) care, specifically during perineal care. The resident's care plan, initiated on 10/2/24, indicated that the resident was incontinent of bladder and bowel and required incontinent checks and care every two hours and as needed, with two-person assistance due to total dependence. However, during an observation on 9/16/25, a CNA provided perineal care to the resident without the required two-person assistance as specified in the care plan. Interviews with the CNA, Executive Director, and Director of Nursing confirmed that the care plan was not followed during the provision of care. The CNA acknowledged not using two-person assistance, and both the Executive Director and Director of Nursing stated that the expectation is for CNAs to follow the care plan and provide proper care. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview, indicating a high level of dependency and vulnerability.