Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, severe cognitive impairment, and significant ADL self-care deficits experienced a fall with injury during care. The resident's care plan and Kardex specified the need for substantial or maximum assistance of two staff members for bed mobility due to weakness and impaired balance. However, a CNA provided care alone, rolled the resident toward herself, and the resident fell out of bed, sustaining a forehead laceration that required hospital transfer and sutures. Staff interviews revealed that the CNA was unaware of the resident's two-person assist requirement and had not received training on the Kardex system during orientation. The DON and LNHA confirmed that the CNA did not follow the resident's plan of care, and the incident was substantiated as neglect. The facility's policy required that residents unable to perform ADLs independently receive necessary services, but this was not followed in this case, resulting in an avoidable accident and injury.