Failure to Follow Care Plan for Toileting and Call Light Placement
Penalty
Summary
Staff failed to follow the care plan for a resident with severe expressive aphasia and anxiety disorder, who was dependent on staff for toileting. The care plan specifically required that the call light be secured to the bedside commode and within reach when the resident was toileting. On the evening in question, two certified nurse aides transferred the resident to the bedside commode but did not place the call light within reach and did not check on the resident for approximately six hours. As a result of these actions, the resident was found on the commode after an extended period, with blanchable redness to both buttocks, a light purple area on the right buttock, and a bruise on the left wrist, which was attributed to the resident banging on the wall for assistance. The resident, who was unable to verbalize needs due to aphasia, was left without a means to call for help and was not monitored as required by the care plan.