Failure to Follow Two-Person Assist Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of a lumbar vertebra fracture and recent acute distal tibia fracture did not receive care according to their established plan, which required two-person assistance for bed mobility, toileting, and transfers. On the date of the incident, an agency CNA provided incontinence care to the resident alone, despite the care plan specifying the need for two staff members. During this care, the resident's right leg came off the mattress and made contact with the floor, which the resident reported caused pain and was followed by a new diagnosis of a distal tibia fracture. The resident, who was cognitively intact and dependent on staff for mobility, described that aides often lifted the pad underneath them to turn or move them, and on this occasion, the CNA moved too quickly, resulting in the leg slipping off the bed. The CNA involved stated that they were not informed of the two-person assist requirement and that it was their first time working at the facility. The facility's documentation and investigation revealed that only one staff statement was obtained, and there was no evidence of staff education or additional interviews with other staff or residents regarding the incident. The facility's own investigation and interviews with the Administrator and DON confirmed that the resident's care plan had not changed before or after the incident and that the resident always required two-person assistance for safety. The lack of adherence to the care plan and insufficient communication to agency staff about resident-specific care needs directly led to the resident sustaining a serious injury during routine care.
Plan Of Correction
F689 Free of Accident Hazards/Supervision/Devices It is the practice of the facility to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated. Element 2: Residents residing in the facility requiring two persons assist for bed mobility are at risk. An audit was completed by the DON/designee of all residents requiring 2 persons assist with bed mobility to ensure their Kardex and care plan were appropriate to ensure adequate support to prevent accidents. Element 3: The interdisciplinary team reviewed the ADL policy and deemed it appropriate for use as written. Licensed nurses and nursing assistants (to include agency staff) will be educated on the ADL policy with emphasis on following Kardex/Care plan when providing assistance with bed mobility and ADL care. In-services will be ongoing as needed. Element 4: The administrator/designee will conduct random audits for residents requiring 2 people to assist with bed mobility to ensure the plan of care was followed weekly for 4 weeks then monthly for three months. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.