Failure to Follow Care Plan Results in Resident Injury Due to Neglect
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and safety precautions for a resident with Alzheimer's Disease, anxiety disorder, and major depressive disorder, who had severely impaired cognition and was dependent on staff for activities of daily living (ADLs). The resident required substantial or maximum assistance of two staff members for bed mobility, as documented in both the care plan and the electronic Kardex system. Despite these requirements, a Certified Nursing Assistant (CNA) provided care alone, rolled the resident toward her, and the resident fell out of bed, sustaining a forehead injury that required hospital transfer and sutures. Interviews revealed that the CNA was unaware of the two-person assist requirement and had not been trained on the Kardex system during orientation. The CNA reported having provided solo care to the resident multiple times previously. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) confirmed that the CNA did not follow the resident's plan of care, and both identified this as neglect. The facility's investigation substantiated that the failure to follow the care plan and lack of staff training directly led to the resident's fall and injury.