Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that residents were transferred according to their care plans, leading to accidents involving two residents. Resident #66, a male with Huntington's Disease and a history of falls, was supposed to be transferred with the assistance of two staff members using a gait belt. However, a CNA attempted to transfer him alone, resulting in the resident falling and sustaining multiple injuries, including lacerations and abrasions. The incident occurred when the resident attempted to reposition himself after being transferred, and the CNA was unable to prevent the fall due to the lack of a second staff member. Resident #78, who was severely cognitively impaired and required assistance with ambulation using a wheeled walker and gait belt, was observed walking independently in the hallway. A CNA assisted the resident to a chair without using a gait belt, contrary to the care plan requirements. The CNA acknowledged the oversight, and the facility's policy mandates the use of gait belts for residents who cannot ambulate independently. These incidents highlight the facility's failure to adhere to care plans and policies designed to prevent accidents.