Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was care planned for two staff assistance. The resident, who had moderately impaired cognition and was dependent on staff for mobility and toileting, was left in the care of a single Certified Nurse Aide (CNA). This CNA provided care alone, contrary to the care plan that required two staff members to assist due to the resident's history of false accusations against staff. During this time, the resident sustained a skin tear and later reported pain in the left arm, which was found to have a fracture. The incident report documented that the resident had risk factors for fractures due to a medical condition that caused brittle bones. Despite the facility's investigation, they could not determine when the fracture occurred, but they concluded it was likely due to the resident's comorbidities rather than the incident itself. The CNA involved admitted to providing care alone and acknowledged the oversight in not following the care plan, which required two staff members to assist the resident. Interviews with staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that the CNA did not adhere to the care plan, which was designed to prevent such incidents. The facility's investigation did not find evidence of abuse, neglect, or mistreatment, but disciplinary action was taken against the CNA for not following the care plan. The facility believed the fracture was due to the resident's brittle bones, although the exact timing of the fracture could not be determined.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 Resident #2’s ADL care plan has been reviewed and was found to be accurate. All other residents’ care plans will be reviewed to ensure that they reflect the appropriate level of assistance required by the residents. The following policy will be reviewed and revised as deemed necessary to ensure that appropriate levels of assistance are care planned for all residents: Comprehensive Care Plan Policy. Clinical Staff will be inserviced on the previously mentioned policy including any revisions and/or policy changes implemented after reviewing such policies. Staff will also be inserviced on “Promoting Resident’s Independence, Resident Rights and Abuse.” The “Promoting Resident Rights and Independence Questionnaire,” which will include components of the ADL Critical Element Pathway, will be conducted weekly and the results of the audits will be compiled and reported monthly to the QAA Committee. The audit will be completed monthly until we achieve 100% for three consecutive months. The Monitoring Log that is used to track Accidents and Incidents across the facility has been edited to include the names of staff members involved in each incident. This will allow for increased surveillance. The findings will be reported in QAA Monthly as part of the Investigation of Accidents/Incidents Audit that is completed by the ADON. The Director of Nursing will be responsible for overseeing this process.