Failure to Follow Care Plan for Fall-Risk Resident Results in Injury
Penalty
Summary
A deficiency occurred when staff failed to implement care-planned interventions for a resident identified as a fall risk. The resident had a history of morbid obesity, decreased mobility, and required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite these documented needs, an agency nurse aide provided in-bed care with only one assist, contrary to the care plan requirements. During routine care, the nurse aide rolled the resident onto his left side to change him after a bowel movement. While being assisted, the resident reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain and was found to have small scratches on his right elbow. Subsequent x-rays revealed an intertrochanteric fracture of the right hip, which was determined to be likely acute in nature. The investigation confirmed that the nurse aide did not follow the resident's care plan, which specified the need for two-person assistance with bed mobility. The aide admitted to providing care alone and was unaware of the specific requirements at the time. This failure to follow the care plan directly resulted in the resident's fall and subsequent injury.