Failure to Follow Care Plans Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that two residents received care in accordance with their comprehensive person-centered care plans, which required two staff members to assist with all activities of daily living. In the first instance, a Certified Nurse Assistant (CNA) provided care to a resident singlehandedly, despite the care plan indicating a need for two-person assistance. This resident, who was completely dependent on others for all activities of daily living and unable to communicate needs, suffered a left mid diaphysis femur fracture after being changed by the CNA without assistance. The CNA did not check the Kardex prior to providing care and was unaware that the resident required two-person assistance for all activities, not just transfers and showers. In the second instance, another CNA changed a different resident's diaper alone, even though the care plan and Kardex specified a two-person assist. This resident was also severely cognitively impaired and completely dependent on others for all activities of daily living. The CNA stated that they often changed the resident alone due to the nurse being busy and did not check the Kardex. The resident later exhibited a swollen leg and a noticeable change in leg alignment, leading to a diagnosis of a right comminuted mid shaft femur fracture. Both incidents highlight a failure to adhere to the facility's Safe Resident Handling policy, which mandates that the number of staff needed for care is indicated in the care plan and Kardex. The CNAs involved did not verify the care requirements before providing care, resulting in significant injuries to the residents. The facility's internal investigations confirmed these lapses in following the care plans, which contributed to the residents' injuries.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Immediate actions for investigation regarding resident #2 included resident assessment by Nurse Practitioner, statement collection from indicated staff, review of medical record, review of Central Monitor pulse oximetry-heart rate data and review of video surveillance. Corrective actions included review of all policies and procedures pertaining to safe positioning and handling, ADL care as well as Osteopenia. Re-evaluation of resident’s care plans by Rehabilitation Services including transfer and ADL care. Comprehensive Plan of Care reviewed and updated on return form ACF and reviewed with caregivers. Review found that resident was identified, and care planned for- at risk for fracture related to immobility and complexity of [DIAGNOSES REDACTED]. #6 was suspended from duty pending investigation with subsequent disciplinary action and remediation for non-compliance with 2-person assist. The resident’s mother was notified and further updated by DNS and Administrator regarding the occurrence, investigative conclusions and updates to plan of care. Immediate corrective actions for investigation regarding resident #3 addressed both non-compliance with 2 person assist, as well as safe positioning for urinary catheterization for contracted residents. Immediate remediation with disciplinary action for CNA #7. Rounds on all units to confirm placement of picture signage with the emoji (not words) of a hand holding up 2 fingers indicating 2-person assist. This emoji is referred to as “I Take 2.” Mandatory acknowledgement for Nursing staff in employee portal of ‘Safe Handling Advisory.’ Corrective action include- Review of all policies and procedures pertaining to safe positioning and handling as well as Osteopenia. Review and updates to Policy and Procedure for Urinary Catheters with additional requirement of alternate positioning needs for procedure to be specified in the plan of care and require a medical order. Re-evaluation of resident by Rehabilitation Services on return from ACF for review of Plan of Care, including positioning for catheterization, transfer and ADL care. Inservices were conducted with nursing staff on these updates to resident #3 plan of care. Parents were notified and updated by DNS and Administrator, they verbalized understanding of resident [MEDICAL CONDITION] diagnosis, active treatment with infusion therapy already in place and continued risk for fracture. They expressed appreciation for the detailed report including updates to ADL care and catheterization. 2) As a corrective action following investigation for resident #2, the policy and procedure for ADL care was revised. As an added safety intervention, ALL residents greater than 35lbs and fully dependent in ADL performance will be two-person assist for all ADL care that requires moving. Review of all 122 residents indicates that 81 residents require 2-person assist. Revision of CNA assignments on all shifts to identify teams for ADL care to facilitate consistent compliance with 2-person assist. Mandatory training with competency assessment for all Nurses and CNAs to include updates to policy and implementation of team assignments. All residents admitted to Sunshine are care planned on admission for risk for Osteopenia and fracture due to the complex medical diagnoses, decreased mobility and non-ambulatory status. Mandatory review inservice was conducted including competency with all Nursing Staff on Osteopenia and Risk for Fracture and Safe Positioning and Handling. Training included use/navigation of resident Kardex to identify resident needs, working together CNA with CNA or NURSE-CNA to ensure safety. In addition, in order to identify others at risk, related to this occurrence for resident #3, a re-evaluation of all Sunshine residents requiring intermittent catheterization was conducted with the Rehab team for need for alternate positioning needs for this procedure. 3) Two-person assist compliance audits were initiated and completed by Nurse Managers and off shift Supervisors. Audits will be continued monthly on all shifts, for a period of 12 months. 4) Monthly audit results and chart reviews will be reported in writing, at least quarterly, to the Administrator and Quality Committee, their findings and corrective actions for a period of not less than 12 months, with ensuing frequency as determined by the Quality Committee. 5) Initiated 10/20/2024 by the Director of Nursing.