Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, consistent with the resident's rights and needs as identified in the comprehensive assessment. The care plan specified that the resident, who had diagnoses including congestive heart failure, varicose veins, and morbid obesity (BMI 45.0 - 49.9), required two-person assistance for activities of daily living (ADLs) such as bathing, bed mobility, transfers, and toileting. Despite these documented requirements, the care plan was not followed during an incident in which a certified nursing assistant (CNA) provided a bed bath to the resident alone, without the required second staff member. On the day of the incident, the CNA turned the resident to her right side during a bed bath, causing the resident to slide off the bed and fall to the floor. The resident sustained a severe laceration to her right hip and a comminuted intertrochanteric fracture to her left hip, requiring emergency medical intervention. The CNA admitted to not reading the Kardex (which contained the care plan and assistance requirements) prior to providing care and acknowledged that she was aware the resident required two-person assistance but did not request help, citing that other aides were busy. Other staff confirmed that the Kardex was accessible and that the resident's need for two-person assistance was clearly indicated. Interviews with facility staff, including the administrator, DON, ADON, and other CNAs, revealed that all direct care staff were expected to refer to the Kardex to determine the level of assistance required for each resident. Staff also stated that it was never appropriate to provide care alone to a resident who required two-person assistance, and that help should always be sought if needed. The failure to follow the care plan and ensure the required level of assistance directly resulted in the resident's fall and injuries.
Removal Plan
- Resident discharged from the facility to the hospital and did not return to the facility.
- The Clinical Service Director in-serviced the nurse managers to include the DON to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care.
- DON/designees in-serviced all direct care (full-time, part-time, and PRN) nursing staff to utilize Kardex to determine the level of assistance required to provide care.
- The Administrator educated CNA A to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. CNA A last day worked.
- All direct care nursing staff (full-time, part-time, and PRN) will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to identify the level of assistance: including 2 person assistance) required to provide ADL care.
- The Kardex was in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan including 2 person assistance.
- DON/designees audited residents' Kardex to ensure the level of required assistance was stated as directed by resident's care plan. Residents were identified as needing 2-person assistance for bed mobility.
- DON/designees audited employee roster to ensure 100% of direct care nursing staff (full-time, part-time, and PRN) are in-serviced to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care.
- The training regarding to refer the Kardex for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance.
- No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' Kardex to determine the level of assistance that is required to provide care.
- DON/designees will conduct random direct care observation audit for compliance with the utilization of the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately.
- The facility Administrator notified the Medical Director via phone.
- Quality Assurance and Performance Improvement review of the plan of removal was completed with the Medical Director.
- Random direct care observation audit will be conducted by DON/designees for compliance with the utilization of the Kardex to determine the level of assistance that is required to provide care to the residents daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months.
- Noncompliance identified will be corrected immediately.
- This will be reviewed monthly in QAPI until sustained compliance is achieved.