Failure to Implement Paired Care Interventions Resulting in Skin Tear
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions requiring paired care for a resident with significant self-care deficits. The resident had a history of CVA, depression, and hemiplegia, was cognitively intact, and was assessed as dependent on staff for toileting hygiene and shower/bathing, and needing partial/moderate assistance with personal hygiene. The comprehensive care plan identified an ADL self-care performance deficit related to dementia, hemiplegia, and limited mobility, and an intervention revised in October 2025 specified that two staff members were to participate in all care for this resident (paired care). A subsequent care plan dated in November 2025 documented that the resident was resistive to care and used foul language or made derogatory statements toward staff. On the date of the incident, a nurse aide provided care to the resident alone, without a second staff member, contrary to the paired care intervention in the care plan. During this care, the resident became agitated while the aide was attempting to clean the resident’s hand. The resident quickly pulled the hand away and sustained a skin tear to the top of the right hand. The resident reported that the aide had hurt the hand and stated an intention to report the aide. The Nursing Home Administrator confirmed that the resident required paired care and that the nurse aide failed to implement the care plan interventions by not providing paired care at the time of the incident.
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