Failure to Implement Two-Person ADL Care Plan for High-Needs Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan that required two-person staff assistance for all activities of daily living (ADLs) and care for a resident with multiple sclerosis, bipolar disorder, borderline personality disorder, generalized anxiety, and antisocial behavior problems. The resident’s quarterly MDS showed intact cognition, total dependence on staff for toileting hygiene, and substantial/maximal assistance needs for personal hygiene and bathing. The resident’s care plan and resident care card both specified that two staff were required for bathing, bed mobility, toileting, personal hygiene, dressing, transferring, and that two staff should be present for extensive assistance with care due to psychosocial and behavioral issues, including accusatory statements toward staff. Facility policies required that ADL assistance be provided per the person-centered evaluation and care plan and that comprehensive care plans be implemented by qualified staff and monitored by clinical department heads. Despite these directives, multiple NAs reported providing care alone. On the night in question, the bladder elimination flowsheet documented that at approximately 5:30 AM the resident was incontinent and care was provided by a single NA, who later confirmed she performed turning, incontinence care, and brief changing by herself, despite knowing the resident was care-planned for two-person assistance. She stated she sometimes did not check the resident care cards and believed one person could perform the care. Other NAs on different shifts also reported independently providing incontinence care, personal hygiene, and repositioning, and one NA stated she had never seen two staff provide ADL care for this resident. The resident later alleged that the night-shift NA was rough and rushed during incontinence care and turning, and interviews with nursing leadership confirmed that, per the care plan, two staff should have been present for ADLs and that this did not occur.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.