Failure to Provide Required Two-Person Assistance During Resident Bathing
Penalty
Summary
A deficiency occurred when a resident, who was assessed to require two-person assistance for bed mobility and bathing due to multiple medical conditions including Multiple Sclerosis, paraplegia, and acute respiratory failure, was provided a bed bath by a single Certified Nursing Assistant (CNA) without the required assistance. The resident's care plan and facility policy both specified the need for two staff members to assist with bed mobility and bathing tasks. Despite this, the CNA proceeded alone, citing that other staff were unavailable and expressing concern about being written up for not completing the task. The resident verbally refused the bed bath, expressing a preference for a shower and stating they could not turn on their side without help. The CNA continued with the bed bath against the resident's wishes and attempted to turn the resident alone, which caused the resident discomfort. The incident was reported by the resident to a recreation aide and subsequently to the Assistant Director of Nursing Services. Multiple staff interviews confirmed that the CNA did not seek or receive assistance from other staff members, despite the resident's documented need for two-person assistance. Documentation and interviews further revealed that the CNA was not familiar with the resident's care requirements and did not review the care instructions prior to providing care. The resident was found to be cognitively intact and able to communicate their preferences and needs. The failure to follow the care plan and obtain the necessary assistance resulted in the resident receiving care that did not align with their assessed needs and preferences, constituting a deficiency in providing adequate supervision and assistance to prevent accidents.