Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement a resident's care plan requiring two-person assistance for bed mobility. The resident, who had diagnoses including spinal cord disease, rheumatoid arthritis, and cervical spondylosis with myelopathy, was severely cognitively impaired and dependent on staff for most activities of daily living. The care plan specified that two staff members were needed for bed mobility due to the resident's physical limitations and chronic pain. Despite this, a Certified Nurse Aide (CNA) provided care alone and attempted to turn the resident without assistance. During this solo care, the resident fell from the bed, resulting in a hematoma and laceration to the head, necessitating transfer to the emergency room. Documentation and interviews confirmed that the CNA did not request help before the incident, and the care plan's requirements were not followed. The Director of Nursing and the Administrator both stated that staff were expected to adhere to care plans, especially for residents requiring extensive assistance.