F0684

E

Failure to Provide Timely Repositioning, Continence Care, and Care Plan–Directed Assistance

Rapid City, South Dakota Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

Non-compliance with F684 occurred when one resident was not repositioned or provided continence care for approximately nine hours during an overnight shift. Camera footage confirmed that between 8:30 p.m. and 5:41 a.m., the resident did not receive repositioning or incontinence care. The facility’s investigation identified that the staff assignment sheet had not been updated to reflect that two CNAs were splitting the overnight shift, and there was no hand-off communication between the CNAs when one left and the other began the split shift. As a result, the resident’s routine checks and care needs were not carried out during that time period.

Additional non-compliance involved another resident whose care plan required "Cares in Pairs," meaning two staff were expected to be present when providing care due to the resident’s history of manipulative behavior, verbal abuse toward staff, recording staff without their knowledge or permission, and making false accusations or statements about staff. Despite this care plan intervention, a CNA assisted the resident with toileting alone, without a second staff member present. The incident was discovered during the investigation of an unrelated event, and there were no adverse consequences reported as a result of this failure. The resident was observed later receiving assistance from two CNAs and reported satisfaction with her care and caregivers.

A third incident of non-compliance occurred when a resident who was assigned to a CNA activated her call light for incontinence care and experienced a significant delay before her brief was changed. At the time the call light was activated, the assigned CNA exited another resident’s room, entered the resident’s room, turned off the call light, and then returned to the previous room instead of providing care. Later, the CNA was approached by a family member of another resident and appeared to respond to that request. More than an hour after the initial call light activation, the resident was heard hollering from her room. Another CNA informed the assigned CNA, who dismissed the hollering as the resident wanting her dinner tray removed. A different CNA was then asked to check on the resident and found that the resident had a bowel movement coming out of her brief, with fecal matter on the bedding that appeared to have been present for some time. The resident later confirmed she had soiled her brief and that it took approximately one and a half to two hours before a CNA came to change her.

Across these three events, the deficiencies centered on failures to provide timely and appropriate care according to orders, care plans, and residents’ needs and preferences. In the first case, lack of updated assignments and hand-off communication led to missed repositioning and continence care. In the second, a CNA did not follow a clearly documented care plan requiring two staff for care. In the third, the assigned CNA did not respond to a resident’s call light and vocal requests for incontinence care in a timely manner, resulting in prolonged exposure to soiled conditions, even though the resident reported that her care was usually provided promptly and that this was an isolated event.