Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided activities of daily living (ADL) care to a resident who required a two-person assist for toileting, transfers, bed mobility, and bathing, without the required second staff member. The resident, who had diagnoses including congestive heart failure, varicose veins, and morbid obesity (BMI 45.0 - 49.9), was cognitively intact and had a care plan specifying the need for two-person assistance for all major ADLs. During the incident, the CNA attempted to turn the resident alone while providing a bed bath, resulting in the resident sliding off the bed and sustaining a severe laceration to the right hip and a fracture to the left hip. The CNA admitted to not reading the Kardex on the day of the incident, despite knowing that the resident required two-person assistance. The CNA stated that she did not want to bother other staff members, felt the facility was short-staffed, and had previously assisted the resident alone. Other staff interviews confirmed that the Kardex was available and indicated the required level of assistance, and that there were enough staff present to provide help if requested. The charge nurse and other CNAs stated that it was standard procedure to refer to the Kardex and to wait for the appropriate number of staff before assisting residents who required two-person assistance. Facility policy required staff to identify and implement interventions to prevent falls and minimize complications, and to avoid neglect by providing necessary care to prevent physical harm. The failure to follow the resident's care plan and facility protocols resulted in the resident's injury. The incident was reported, and staff interviews and documentation confirmed that the CNA acted alone, contrary to the resident's care requirements and established procedures.
Removal Plan
- Resident #1 involved in alleged deficient practice was discharged to the hospital and did not return to the facility.
- CNA A was in-serviced on referring to the Kardex for the level of assistance required by residents with ADL care and the Abuse and Neglect Policy by the administrator.
- CNA A was suspended pending investigation findings.
- The Administrator notified the Medical Director of the alleged deficient practice.
- CNA A's last day employed.
- The Corporate Clinical Service Director re-educated the nurse management team on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy.
- The Administrator and Nurse Managers re-educated the nursing staff on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy.
- An audit was conducted by the Corporate Clinical Service Director and the nurse management team to ensure the level of ADL care required, including residents needing 2-person assistance was noted in the Kardex. Discrepancies found were immediately corrected.
- The Corporate Clinical Service Director reviewed facility policy regarding change in condition and no revisions were deemed necessary.
- The Regional Nurse completed Resident Life Satisfactory Surveys for residents that require 2-person assistance, no concerns were noted.
- The nurse management team re-educated the nursing staff (Full-time, Part-time, and PRN) on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. Nursing staff will not be allowed to return to work until they receive this in-service.
- Newly hired nursing staff will be in-serviced upon hire during staff orientation by nurse management/designee on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy.
- DNS/designee will conduct random observations of ADL care including residents needing 2-person assistance is being provided daily for one week, then weekly for one month, and monthly thereafter until compliance is sustained for three consecutive months. Noncompliance identified will be addressed immediately.
- The ADONs will review the change in condition daily for any changes in residents' ADL level of assistance requirements and ensure the Kardex is updated as applicable. Discrepancies noted during reviews will be immediately corrected. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form.
- The Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction. The review will be documented on an audit report form.
- A Quality Assurance and Performance Improvement review of the plan of removal was completed with the Medical Director. The Medical Director has reviewed and agrees with this plan.