Neglect Leads to Resident Injury Due to Inadequate Assistance
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a significant injury. A Certified Nursing Assistant (CNA) was providing care to a resident, identified as Resident #999, and attempted to turn the resident on his left side to remove his brief and bed sheet. During this process, the resident moved off the bed and fell, sustaining a red discoloration and a hematoma on the right side of his body. The resident was subsequently transferred to a local hospital and diagnosed with an acute intra-axial injury within the left frontal region. The investigation revealed that the CNA did not follow the facility's policy and procedures, which required reviewing the resident's Kardex for specific care instructions. The Kardex indicated that Resident #999 required the physical assistance of two persons for bed mobility, a detail that was not communicated to the CNA. The CNA, unaware of this requirement, attempted to reposition the resident alone, leading to the fall. The CNA admitted to not knowing about the Kardex and stated that she had always assisted the resident by herself without being informed of the two-person assist requirement. Interviews with facility staff, including the Unit Manager and other Registered Nurses, confirmed that the Kardex is regularly updated and should be reviewed at the beginning of each shift. However, the CNA did not receive this information prior to the incident. The facility verified the neglect allegation and noted that the CNA would be terminated for failing to adhere to the established procedures. The resident's care plan and admission assessments clearly indicated the need for two-person assistance, which was not communicated effectively to the CNA involved in the incident.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On [date], upon immediate discovery, resident #999 was assessed, received first aid, and transferred to a higher level of care for further evaluation and treatment as indicated. - On [date], investigation immediately initiated, Staff member A suspended pending the outcome of the investigation. - On [date], staff member A along with the Executive Director performed a reenactment of the incident that resulted in a mechanical [incident]. It revealed the stakeholder failed to follow policy and performed toileting hygiene, which includes bed mobility independently. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective actions will be taken: - A quality review was performed on [date] by the Executive Director and DCS of all residents that reside in the facility in which staff member A provided care to ensure no other residents sustained a [incident] due to improper bed mobility and were free from [incident] or neglect. No discrepancies noted. - A quality review was performed on [date] by the Director/DCS/UM of all residents that reside in the facility of their Kardex and Careplan ensuring that bed mobility was present and accurate. No noted discrepancies. The information was present, accurate, and accessible to all nursing staff. 3. What measures will be put in place or what systemic changes you will make to ensure that the practice does not recur: - On [date] and ongoing, the nursing staff re-educated by the DCS/Designee regarding the components of this regulation with the emphasis on the following: "Kardex use - ensuring the Kardex is reviewed and followed prior to providing care for the resident." - "Bed mobility - ensure proper bed mobility is used to include but not limited to the correct number of people to complete the task and always roll a resident towards you never away. Ensure the proper number of people are present to perform the task(s)." - And ongoing, all staff re-educated by the DCS/designee regarding the components of this regulation with the emphasis on the following: neglect and - ensure that while providing care, policies and procedures are being adhered to and no intentional neglect is being performed while providing care. - "On [date] - ongoing the implementation of enhanced task added to the Kardex for a quicker review for staff to see the residents' need for assistance such as: dependent, extensive, limited, supervision, or independent care needed." 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 the Kardex has the enhanced task present." - "Ensure task for new admissions and residents with a change in ADLs are promptly updated to reflect current condition." - "Ensure policy and procedures are being followed." - "Ensure stakeholder(s) are not providing neglectful care." - The findings of these quality monitoring to be reported to the Quality Assurance Program Improvement Committee monthly. Quality monitoring schedule to be modified based on the findings with quarterly monitoring by the Regional Director of Clinical Services/designee.