Failure to Specify Assistance Needed for Bed Mobility and Incontinent Care in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that specified the amount of assistance required for incontinent care and bed mobility for a resident with severe cognitive impairment and significant physical limitations. Despite documentation and staff observations indicating that the resident frequently required two-person assistance for these activities, the care plan did not reflect this need. The care plan only addressed two-person assistance for transfers with a mechanical lift and fall risk interventions, omitting explicit instructions for bed mobility and incontinent care. Multiple assessments and documentation reports showed that the resident was dependent on staff for rolling and was incontinent of urine, with frequent instances where two staff members provided assistance for toileting and bed mobility. However, staff interviews revealed inconsistencies in the understanding and implementation of the required level of assistance, with some staff stating that one-person assistance was sometimes used, while others reported always using two-person assistance. The lack of clear, consistent care plan directives contributed to confusion among staff regarding the resident's needs. An incident occurred in which the resident fell out of bed during incontinent care, resulting in significant injuries, including a fracture and hematoma. The incident report and subsequent interviews indicated that the fall happened when a single CNA attempted to reposition the resident without adequate assistance, as the care plan did not specify the required two-person assistance for bed mobility and incontinent care. This deficiency in care planning and communication directly contributed to the resident's injury.