Failure to Follow Care Plan Requiring Two Staff During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of making accusatory statements against staff. The resident, who had diagnoses including transient ischemic attacks, mood disorder, and psychotic disorder with delusions, required assistance from two staff members for all care due to their behavioral history. The care plan and nurse aide care card both specified that two staff members should be present during care. However, on the date of the incident, one nurse aide provided care to the resident alone, contrary to the care plan directives. This failure was identified after the resident reported to a nurse that the aide was rough and had shoved them onto the toilet, nearly causing a fall. Documentation and interviews confirmed that the second aide was not present during the care, as required. The Director of Nursing acknowledged that the care plan was not followed, and the facility policy required staff to be informed of their responsibilities regarding care plan interventions. The incident was not substantiated as abuse, but it was determined that the care plan was not properly implemented.