Failure to Follow Care Plan for Resident Assistance
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident, leading to a deficiency. Specifically, the care plan for the resident required a maximal assist of two staff members for bed mobility, including rolling in bed. However, a Certified Nurse Aide (CNA) provided care independently, rolling the resident and placing them on a bedpan without assistance. This action was contrary to the care plan, which was designed to meet the resident's medical, physical, and psychosocial needs. The resident involved was cognitively intact and able to communicate effectively. The care plan, dated over two years prior, specified the need for two staff members to assist with bed mobility. Despite this, the CNA did not review the care plan before providing care, relying instead on their familiarity with the resident. The CNA admitted to not consistently reviewing care plans unless there was a reported change in the resident's condition, which contributed to the oversight. Interviews with various staff members, including Registered Nurses, Licensed Practical Nurses, and the Director of Nursing, revealed an expectation that care plans should be reviewed prior to providing care to ensure resident safety. The failure to adhere to the care plan was acknowledged as a break in protocol, emphasizing the importance of following care plans to prevent such deficiencies. The incident was reported, and an investigation was initiated, confirming the CNA's deviation from the care plan.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Action Taken for the Resident Identified The resident was assessed immediately by nursing staff, and no injury was sustained. The incident was self-reported to the Department of Health. The CNA involved in this incident is no longer employed at this facility. The resident’s care plan was reviewed with no changes at this time. Identification of Other Residents Who Could Be Affected A facility-wide review will be conducted for all residents requiring 2-person assist for bed mobility, transfers, or ADLs. The review will include audits of care plans and direct observation of CNA compliance. Systemic Changes Made to Prevent Recurrence Mandatory in-service training will be completed for all CNAs and nursing staff covering: - Reading and interpreting care plans - The importance of following assistance level requirements - Reporting discrepancies or uncertainties immediately Monitoring and Quality Assurance - The Unit Managers or designee will conduct weekly audits of 5 resident care plans per unit and corresponding staff performance for 8 weeks to ensure care is delivered per plan. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - If 100% compliance is observed for 8 weeks, audits will reduce to monthly for 3 additional months. Person Responsible: Director of Nursing or Designee