NOBLESVILLE, IN - Federal inspectors cited Harbour Manor Health & Living Community after staff failed to follow a critical care plan intervention designed to protect a vulnerable resident, leading to allegations of inappropriate touching by a certified nursing assistant.
Care Plan Violation Preceded Serious Allegation
During a January 2, 2025 complaint investigation, inspectors discovered that facility staff had not followed an established care plan requiring two-person care for a resident with multiple sclerosis and other serious medical conditions. The resident, identified as Resident C in the inspection report, reported that on December 26, 2024, during the night shift, CNA 3 touched him inappropriately during incontinence care.
The facility had implemented a specific intervention requiring care in pairs for this resident on November 7, 2023, due to documented behavioral concerns and a history of making allegations against staff members. This safety protocol was clearly outlined on the CNA Assignment Sheet and in the resident's care plan dated April 28, 2023.
Medical Complexity Heightened Need for Protection
Resident C's medical record revealed multiple serious conditions that would make him particularly vulnerable during personal care situations. His diagnoses included multiple sclerosis, an abdominal aortic aneurysm without rupture, type 2 diabetes with complications including polyneuropathy and hyperosmolarity, depressive disorder, and dysphagia following a stroke.
Multiple sclerosis affects the central nervous system and can cause muscle weakness, mobility issues, and cognitive changes, though the resident's most recent quarterly assessment from November 5, 2024, indicated he remained cognitively intact. Diabetic polyneuropathy affects nerve function and can cause numbness or altered sensation, while his history of stroke-related swallowing difficulties added additional complexity to his care needs.
These medical conditions collectively created a situation where the resident required careful, professional handling during intimate care procedures. The combination of physical vulnerability from his neurological conditions and his documented behavioral concerns made the two-person care protocol essential for both his protection and staff safety.
Staff Acknowledged Required Protocol
Multiple facility staff members confirmed during interviews that they understood Resident C required two-person care. CNA 4 told inspectors on January 2 that "staff provided care to Resident C in pairs due to his behaviors." Similarly, CNA 5 confirmed that "Resident C required two staff members when care was provided" and noted this intervention was clearly listed on the CNA Assignment Sheet.
The Director of Nursing (DON) explained that Resident C had approached her to report the alleged physical assault by CNA 3. Following standard protocol, the facility initiated an investigation and sent the resident to the hospital for medical evaluation. However, the DON confirmed that CNA 3 had provided care alone while another CNA was in the hallway, representing a clear violation of the established care plan intervention.
Investigation Reveals Protocol Breakdown
CNA 3 submitted a written statement dated December 27, 2024, confirming they had provided care to Resident C on December 26, 2024. Significantly, the aide's statement did not indicate whether another staff member had been present during the care provision, as required by the facility's own protocols.
This omission in the written statement, combined with the DON's confirmation that the aide had worked alone, demonstrated a breakdown in the facility's implementation of its own safety measures. The two-person care requirement existed specifically to prevent such allegations and protect both residents and staff from compromising situations.
Care Plan Interventions Serve Critical Safety Function
Care plan interventions requiring two-person care typically arise from documented incidents or behavioral patterns that create risk for either residents or staff. These protocols serve multiple protective functions: they provide witnesses to care interactions, reduce opportunities for inappropriate conduct, and help manage residents who may become confused or agitated during personal care.
For residents with complex medical needs like Resident C, these interventions become even more crucial. The combination of physical vulnerability, potential cognitive changes from neurological conditions, and documented behavioral concerns creates a high-risk situation that requires strict adherence to established protocols.
Regulatory Standards for Care Plan Implementation
Federal nursing home regulations require facilities to develop and implement complete care plans that meet all resident needs, with specific timetables and measurable actions. When facilities identify interventions necessary for resident safety and wellbeing, staff must consistently follow these protocols.
The failure to implement care plan interventions not only violates federal standards but potentially exposes vulnerable residents to harm. In this case, the breakdown in protocol led directly to a serious allegation that required hospital evaluation and facility investigation.
Facility Response and Investigation
Following the resident's report, Harbour Manor initiated an internal investigation and arranged for hospital evaluation, demonstrating appropriate immediate response procedures. However, the incident highlighted the importance of preventing such situations through consistent adherence to established safety protocols.
The facility's own staff confirmed understanding of the two-person care requirement, indicating the violation resulted from implementation failure rather than lack of awareness. CNA 3 was not available for interview during the federal inspection, limiting investigators' ability to fully understand the circumstances surrounding the protocol violation.
Industry Standards for Vulnerable Population Protection
Nursing homes serve highly vulnerable populations, with many residents experiencing cognitive impairment, physical disabilities, or complex medical conditions that affect their ability to protect themselves. Federal regulations recognize this vulnerability by requiring comprehensive care planning and consistent implementation of safety measures.
Two-person care protocols represent one of several tools facilities use to protect residents while ensuring staff can provide necessary intimate care safely and professionally. These measures become particularly important for residents with documented behavioral concerns or those who have previously made allegations against staff.
The violation at Harbour Manor underscores the critical importance of consistent protocol adherence in protecting nursing home residents. When established safety measures fail, the consequences can include serious allegations, regulatory violations, and potential harm to the vulnerable individuals these facilities serve.
Federal inspectors classified this violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident demonstrates how care plan implementation failures can create serious risks for nursing home residents who depend on facility staff for their most basic and intimate care needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbour Manor Health & Living Community from 2025-01-02 including all violations, facility responses, and corrective action plans.
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