Single CNA Provides Care Against Care Plan Requirements
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with their comprehensive person-centered care plan. Specifically, the care plan for the resident required assistance from two staff members for all care activities. However, on one occasion, a single Certified Nurse Aide (CNA) provided care to the resident alone. This action was contrary to the care plan, which specified that two caregivers were necessary for tasks such as bed mobility and transfers. The resident, who was wheelchair-bound and dependent on others for all care, was at risk for significant bone fragility due to chronic immobilization and medication use. Following the unauthorized single-person care, the resident exhibited signs of discomfort and swelling in the left thigh, prompting a transfer to the hospital to rule out a fracture. The facility's internal investigation, including video surveillance review, confirmed that the CNA repositioned the resident without assistance, using a chuck to move the resident. The resident's care plan had been reviewed and documented the need for two-person assistance to prevent abuse, neglect, and mistreatment, which was not adhered to during this incident.
Plan Of Correction
Plan of Correction: Approved April 8, 2025 I. Corrective Action: 1. Staff CNA #1 suspended for five days. 2. CNA #1 re-educated on reviewing Nursing Instructions through the EMR system prior to providing ADL care. II. Potential of other Residents to be affected: 1. Video of the residents on the CNAs assignment were reviewed and no other residents were affected. 2. Since (MONTH) 24, 2024, 369 videos were reviewed to ensure compliance with care plans. 3. All direct care staff are to be re-educated on the Personal Hygiene Policy, which was revised to include verifying Nursing Instructions via the EMR system. III. Measures and Systemic Changes: 1. Revised Personal Hygiene Policy on 3-25-25 to include CNA’s verifying Nursing Instructions via the CNA kiosk (Nursing Instructions replicate resident ADL support needs as outlined in the Care Plan). 2. Re-educate all direct care staff by (MONTH) 30th, 2025. IV. Monitoring Corrective Actions: 1. Personal Hygiene Policy education will be reported to the Quality and Safety Committee upon completion. 2. 30 in-person ADL observations will be conducted monthly by Nurse Managers/Supervisors for 60 days. Any non-compliance will be addressed immediately. 3. Completion of the Plan of Correction will be reported to the Quality and Safety Committee. V. Date of Correction and Title of Person responsible for correction of deficiency: Corrective Action Completion date: 5-9-2025 The Director of Nursing is responsible for the corrective action.