Failure to Update Care Plan Results in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan to reflect the need for two staff members to assist with bed mobility, as assessed by physical therapy. The resident, who had diagnoses including generalized osteoarthritis, transient ischemic attacks, and a history of repeated falls, was determined by physical therapy to require total dependence and maximum assistance of two staff for bed mobility due to increased weakness, instability, and hypotension. Despite this assessment, the care plan continued to indicate only one staff member was needed for bed mobility, and this information was not communicated or incorporated into the resident's care plan. On the day of the incident, a certified nurse aide provided incontinence care and attempted to reposition the resident in bed alone. During this process, the resident was rolled too close to the edge of the bed, resulting in the resident's head and legs hanging over the side. The aide was unable to return the resident to bed and, while attempting to lower the resident to the floor, lost balance, causing both to fall. The resident landed on their left side and initially complained of pain to the right elbow, but later reported severe pain in the right hip. Subsequent assessment revealed a femoral neck fracture, and the resident was transferred to the hospital, where additional complications including septic shock, myocardial infarction, and respiratory failure were documented. The resident was placed on comfort care and expired at the hospital. The facility's investigation confirmed that the care plan was not updated to reflect the physical therapy assessment, and there was no follow-up training or education for staff regarding falls after the incident.