Failure to Implement Care Plan Leads to Resident Falls
Penalty
Summary
The facility failed to implement care plan interventions to prevent accidents and related injuries for a resident with multiple falls. The resident, who was severely cognitively impaired and dependent on staff for toileting, was observed being assisted by only one CNA, contrary to the care plan that required two staff members for toileting assistance. The CNA, who was an agency staff member, was not familiar with the facility's Kardex or the specific care requirements for the resident, leading to inadequate supervision during toileting. The resident had a history of multiple falls, some resulting in minor injuries, and was found on the floor on several occasions. Despite updates to the care plan, such as frequent checks and reminders for the resident to call for assistance, these interventions were not effectively communicated or implemented. The facility's failure to ensure that the care plan was followed and that staff were adequately trained contributed to the resident's repeated falls. Interviews with facility staff revealed gaps in training and communication regarding the resident's care needs. The Assistant Director of Nursing acknowledged that the CNA should have had a second staff member present during toileting to prevent accidents. Additionally, the use of mats requested by the resident's family was not documented in the care plan, and a planned training program for fall prevention was not implemented. These oversights highlight the facility's failure to provide adequate supervision and assistance devices to prevent accidents, as required by regulations.
Plan Of Correction
1. Resident #12's care plan updated with two-person assist, mats, and implemented programming. 2. All high-risk residents' care plans reviewed, referrals made, and care plans updated as necessary initiated completed. 3. Staff re-educated on use of Kardex, interventions, and toileting support initiated with projected completion. 4. Daily review in clinical meeting, weekly audit at risk meeting ongoing and reported to QA committee monthly. Reviewed in QAPI. 5. Report to QA committee will continue monthly for recommendations and or revisions. Completion Date: