F0656

D

Failure to Follow Toileting Care Plan Leading to Fall During Stand Aid Use

South Range, Wisconsin Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident received person-centered care in accordance with the comprehensive care plan, specifically related to toileting assistance and use of a stand aid. The resident had a BIMS score of 6/15, indicating severe cognitive impairment, and the care plan specified stand aid assist of one staff member for transfers, but assistance of two staff for toileting before morning cares, at bedtime, every 2–3 hours while awake, and upon request. On the date of the incident, a CNA entered the resident’s room for incontinence care and assisted the resident to a standing position in the stand aid without a second staff member present. While the resident was standing in the stand aid, the CNA attempted to pull down the resident’s pants to change the incontinent brief.

During this process, the resident stated they could no longer stand, and their feet slipped off the stand aid platform. The CNA attempted but was unable to reposition the resident’s feet on the platform and subsequently had to lower the resident to the floor. Later interview with the resident confirmed they recalled falling and breaking a foot but could not recall the details or staff involved. Interviews with facility staff, including CNAs, the Rehab Director, and the Nursing Home Administrator, confirmed that care plans are accessible to CNAs, that staff are expected to follow the care plan, and that the stand aid is intended for transfers only and not for standing a resident during incontinence product changes. Staff also stated that if a care plan requires two-person assist for toileting, they would not use the stand aid alone to change an incontinent resident, underscoring that the care plan was not followed in this incident.