Failure to Care Plan for Known Grabbing Behavior Resulting in Resident Injury
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with a known behavior of grabbing onto objects while being transported in a wheelchair, which resulted in a fall and injury. Multiple staff members, including CNAs and nurses, were aware that the resident frequently grabbed onto items such as rails, tables, and other wheelchairs during transfers, and this behavior had been observed since the resident was moved to the second floor. Despite this, the behavior was not care planned or addressed with specific interventions prior to the incident. On the day of the incident, a CNA was transporting the resident out of the dining room when the resident grabbed the wheel of another resident's wheelchair, causing her hand to become caught and leading to a fall. The resident sustained a closed fracture of the index finger and a contusion with swelling on the forehead. The incident occurred because the path was not cleared of other wheelchairs, and the staff did not implement any interventions to mitigate the known risk associated with the resident's behavior. The resident had a history of falls, severe cognitive impairment, and dementia, as documented in her medical records. Staff interviews confirmed that the behavior of grabbing onto objects was well known among staff but was not included in the resident's care plan until after the incident. The lack of a care plan and failure to update it when the behavior was first observed contributed directly to the resident's injury.