Failure to Follow Two-Person Assistance Care Plan During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan requiring two staff to be present for all care provided to a bedfast resident with significant physical impairments. The resident was an elderly female with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and a contracture of the left hand. An MDS assessment documented that she did not speak and required substantial assistance for all functional needs, including toileting, hygiene, transfer, and dressing. Her care plan dated 11/25/2025 specified that she was bedfast and required two staff to assist with all personal care needs, including bathing, toileting, bed mobility, dressing, eating, and transfers. A progress note from the same date indicated she required two people to assist with toileting, and an ADL sheet in the nurse’s station binder stated that two people were to be in the room any time care was provided. On one occasion, video footage from the resident’s room showed that a CNA performed incontinent care alone, contrary to the care plan. The video from 1/7/2026 at 2:31 p.m. showed CNA B completing incontinent care while the resident’s bed was raised and pulled away from the wall. CNA B adjusted a fabric incontinent pad under the resident while she was rolled on her right side, then rolled her onto her back, placed a pillow under her legs, and positioned a wedge pillow by her right side. The only other person present in the room was a visitor seated against the opposite wall, who did not assist with care and was observed watching and using a phone. A grievance/concern report documented that the DON recorded information that CNA B had conducted incontinent care by herself on that date after the resident’s family member yelled at her to change the resident and threatened to call the State if she did not. On another occasion, video footage showed a second CNA also providing incontinent care alone, again in conflict with the resident’s care plan. The video from 1/10/2026 at 3:49 p.m. showed CNA C performing incontinent care with the bed raised and against the wall. CNA C unfastened the resident’s incontinent brief, placed it between the resident’s legs, then placed her hands behind the resident’s knees and pulled her toward herself to push the brief under her. CNA C rolled the resident onto her right side toward the wall and held her in that position with one hand while completing the care. No other staff were present in the room assisting with care. In interviews, the LVN and DON confirmed that the care plan required two staff to be in the room for any tasks for this resident and that it would not be appropriate to complete a two-person task alone, as the directive in the care plan was for resident safety.
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