Failure to Follow Two-Person Assist for Bed Mobility
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided peri-care to a female resident with dementia, morbid obesity, and right-sided weakness and paralysis following a stroke, without following the resident's care plan intervention. The care plan specified that the resident was dependent on two staff members for bed mobility. However, during the observed care, only one staff member was present to assist the resident with bed mobility, and the CNA instructed the resident to roll onto her sides without additional assistance. This action was not in accordance with the documented safety intervention for the resident.
Plan Of Correction
F tag 689 Accidents SS=BAccidents 1. Resident #25 was evaluated to determine if any injuries were sustained due to staff's failure to follow the care plan/Kardex during repositioning the resident. No injuries noted due to deficient practice. The CNA involved received 1:1 education. 2. Residents who reside in-house are at risk due to the deficient practice. Residents in-house who sustained an accident in the last 10 days were reviewed by the nursing team to ensure that the care plan was followed and that the accident didn't occur based on failure to follow the care plan. Any concerns will be addressed. 3. The QAPI Committee reviewed the Standards of CNA/STNA Practice and deemed it appropriate. CNA's were re-educated by the DON/Designee on the Standards of CNA/STNA Practice. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review residents with accidents weekly times four to ensure that their care plans are being followed, then monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for ongoing direction and further guidance. The NHA is responsible for continued compliance.