Failure to Follow Care Plans for Transfers and Supervision Results in Resident Injuries
Penalty
Summary
The facility failed to implement safety measures as indicated in the care plans for two residents, resulting in significant injuries. One resident, with diagnoses including chronic obstructive pulmonary disease, lumbar radiculopathy, and a need for assistance with personal care, was care planned for dependent transfers requiring two staff members and the use of a mechanical lift. Despite this, the resident was transferred from wheelchair to bed by a single CNA using a stand-pivot method, during which the resident's left leg struck the lever of the bed's halo, causing a laceration that required hospital treatment and sutures. Documentation and staff interviews confirmed that the resident's care plan and transfer requirements were not followed at the time of the incident. Another resident, with a history of moderate intellectual disabilities, lack of coordination, and a history of falls, required substantial assistance with bed mobility and was care planned for assistance by one to two staff as needed. After being transferred into bed by a CNA, the resident was left momentarily unattended while the CNA turned away after providing incontinence care. During this brief period, the resident attempted to reach for personal comfort items and slid out of bed, resulting in a fall and subsequent diagnosis of an intraparenchymal hematoma. The care plan specified that essential and personal items should be kept within reach, but the resident's attempt to access these items led to the fall. In both cases, staff interviews and record reviews indicated that the established care plans and facility protocols for safe transfers and fall prevention were not consistently followed. The incidents were attributed to staff not adhering to the required level of assistance during transfers and not maintaining appropriate supervision during care activities, directly leading to the residents' injuries.