Failure to Follow Two-Person Assist Care Plan for Dependent Resident
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, chronic respiratory failure, severe osteoporosis, a tracheostomy, and an above-the-knee amputation. The resident's care plan specified a self-care performance deficit and required two staff members to assist with repositioning, dressing, personal hygiene, oral care, and toileting due to impaired balance, limited mobility, and bilateral hand/wrist contractures. However, video footage reviewed by a police detective and confirmed by staff interviews showed that the resident was frequently repositioned and provided incontinence care by only one staff member, contrary to the care plan requirements. Staff interviews, including those with a registered nurse, two certified nursing assistants, the administrator, and the director of nursing, all confirmed that the resident required two-person assistance for incontinence care and repositioning. Despite this, the video evidence demonstrated that care was often provided by only one staff member. The deficiency was identified during a complaint investigation, and the administrator and DON were notified of the findings, which were corroborated by the detective's review of the video footage and staff statements.