Failure to Follow Care Plans for Supervision and Transfer Leading to Deficiencies
Penalty
Summary
A deficiency occurred when an agency CNA failed to follow a resident's care plan requiring 'cares in pairs' for a resident with ataxic cerebral palsy, delusional disorder, major depressive disorder, and epilepsy. The resident, who was cognitively intact, had a care plan and care sheet indicating that two staff members were required to be present during care due to a history of embellishing or fabricating stories. Despite this, the agency CNA provided care alone, which led to an allegation of inappropriate touching. The resident's care plan was clearly marked, and the CNA had received training on the 'cares in pairs' procedure prior to the incident. Another deficiency was identified when a CNA did not follow the care plan for a resident with traumatic subarachnoid hemorrhage, insomnia, dysphagia, depression, hypertension, and repeated falls. The resident, who was severely cognitively impaired, required a total body mechanical lift with two staff members for all transfers, as documented in both the care plan and care sheet. The CNA transferred the resident using a gait belt instead, resulting in a fall. The CNA had previously sought clarification from therapy staff but misunderstood the instructions, and the care plan had not changed. Both incidents involved staff not adhering to the individualized care plans and care sheets, which were clearly documented and communicated. In both cases, the staff involved had current certifications, completed required trainings, and had no background check concerns. The deficiencies were identified through interviews, record reviews, and facility-reported incidents.