Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in harm. A resident who had recently been admitted following a hip fracture and surgery required extensive assistance from two staff members for bed mobility, as documented in the care plan and Kardex. Despite this, a nurse aide provided care alone and attempted to roll the resident in bed for a complete bed change. During this process, the resident rolled out of bed and fell to the floor, sustaining a nasal bone fracture, an acute nondisplaced fracture of the odontoid process, and a scalp laceration requiring sutures. The nurse aide involved had received education on the facility's abuse and neglect policy, as well as on reviewing the resident's Kardex prior to providing care. However, the aide admitted to not reviewing the Kardex before assisting the resident and was unaware of the requirement for two-person assistance. The Director of Nursing confirmed that the aide's failure to follow the care plan directly resulted in the resident's fall and injuries.