Failure to Implement Care Plan Leads to Resident Harm
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who required a two-person assist for bed mobility, transfers, and all activities of daily living. This deficiency was identified during an abbreviated survey, where it was found that staff did not implement the necessary interventions as per the resident's care plan. The resident, who had severe cognitive impairment and functional limitations, was involved in two separate incidents where staff failed to follow the care plan, resulting in harm. In the first incident, a Certified Nurse Aide found the resident on the floor and used a Hoyer lift alone to move the resident back into bed, contrary to the policy requiring two certified/licensed staff members for such transfers. The resident was found with a lump on the forehead, a swollen and deviated nose, and bleeding from the right nostril. Despite the resident's severe cognitive impairment and inability to communicate, the staff member did not call for help before moving the resident, which was against the facility's policy. In the second incident, another Certified Nurse Aide provided care to the resident alone, resulting in the resident bumping their head on the bedside table. This incident also violated the care plan, which required a two-person assist. The resident sustained a hematoma and a nosebleed, and was later diagnosed with a brain bleed, broken neck, and extensive facial fractures at the hospital. The Medical Examiner noted that the extent of the injuries was not consistent with the explanations provided, and the manner of death could not be determined.