Failure to Document and Communicate Care Needs Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that safety interventions were documented in the care plan and that staff used safe repositioning techniques, leading to an avoidable injury for Resident #999. The resident, who had decreased cognition and mobility, required the physical assistance of two persons for bed mobility, as noted in the New Admission Evaluation form. However, this requirement was not specified in the care plan or the Kardex, which is used for communication and organization of resident care summaries. During an incident, Certified Nursing Assistant (CNA) Staff A was changing Resident #999 and attempted to reposition him without assistance. The resident began to move off the bed, and despite CNA Staff A's attempt to hold him, he fell to the floor, resulting in a hematoma and other injuries. The CNA was unaware that the resident required two-person assistance, as this information was not documented in the Kardex or communicated to her. The facility's investigation revealed that CNA Staff A had not been informed of the two-person assist requirement and had not encountered issues with the resident previously. The investigation also noted that the resident was not positioned correctly during the repositioning attempt, contributing to the fall. The lack of proper documentation and communication regarding the resident's care needs led to the deficiency in providing adequate and appropriate health care services.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Upon immediate discovery, the resident #999 received first aid and was transferred to a higher level of care for evaluation and treatment as indicated by Staff member B. - Resident #999 no longer resided at the facility. 2. How will you identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - Quality review performed by DCS/designee of the residents in which Staff member A provided care to ensure no other resident sustained injuries related to her failure to follow the Kardex and policy and procedures for bed mobility (assist of 2-dependent care). No deficient practice noted. - Quality review performed by DCS/designee of all residents that reside in the facility to ensure no injuries were sustained during care and stakeholders were utilizing the Kardex to provide proper care. No deficient practice noted. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - Ongoing nursing staff re-educated on the components of this regulation with emphasis on: - Stakeholders aware to review Kardex prior to providing care. - Stakeholders are to ensure they have the correct number of staff members to provide care. - Stakeholders are to ensure proper bed mobility (always turn a resident toward you, not away). - Ensure stakeholders are efficient and familiar with policy, procedures, and processes prior to caring for residents through continual education, competencies, and monitoring. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what Quality Assurance program will be put in place: The DCS/designee will conduct audits on 10 residents weekly x 4, then bi-weekly x 4, then monthly x 1 and PRN on the following: - Ensure resident is free from injury while receiving care. - Ensure Kardex is followed and appropriate care provided. The findings of these quality monitoring will be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services/designee.