Failure to Follow Two-Person Assist Care Plan During Incontinence Care
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with paraplegia and Multiple Sclerosis, who required two-person assistance for incontinence care and repositioning. The resident, who had intact cognition, was care-planned for two-person assistance as documented in the Care Plan Kardex. Despite this, a Certified Nursing Assistant (CNA) provided incontinence care alone, without the required second staff member present. During the incident, the resident fell out of bed while being changed by the CNA, who admitted to performing the care alone due to insufficient staffing. The Director of Nursing Services confirmed that the care plan required two-person assistance and that the CNA did not follow this directive. The facility's policy and the resident's care plan both specified the need for two-person assistance, which was not adhered to at the time of the fall.