Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of muscle weakness and repeated falls was not provided the care as outlined in his care plan. The resident required assistance from two staff members for bed mobility, as documented in his care plan and Kardex. However, on the date of the incident, an agency CNA provided care alone and attempted to move the resident in bed without the required second staff member present. During this process, the resident fell from the bed, resulting in abrasions to his face, knees, and a bleeding wound on his toe. The incident report and interviews confirmed that the CNA did not review the care plan or Kardex prior to providing care and did not consult with nursing staff or other personnel before proceeding. The resident was found on the floor, partially under the bed, after the fall. The DON confirmed that the CNA was alone in the room at the time of the incident, which was not in accordance with the resident's care plan requirements for a two-person assist during bed mobility.