Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injuries
Penalty
Summary
A deficiency occurred when a resident, who had recently undergone surgery for a hip fracture and required extensive assistance from two staff members for bed mobility, was left under the care of only one nurse aide. The resident's care plan, which specified the need for two staff during bed mobility, was not followed. The nurse aide, without reviewing the resident's Kardex or care plan, attempted to perform a complete bed change alone. During this process, the resident rolled out of bed and fell to the floor. As a result of the fall, the resident sustained multiple injuries, including a nasal bone fracture, an acute nondisplaced fracture through the base of the odontoid process, and a left frontal scalp laceration requiring sutures. The nurse aide later admitted to not reviewing the care plan prior to providing care and was unaware of the two-person assistance requirement. The Director of Nursing confirmed that the failure to follow the resident's care plan for bed mobility led to the resident's fall and subsequent injuries.