Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the established plan of care for a resident who required extensive assistance with activities of daily living due to conditions such as disease of the spinal cord, rheumatoid arthritis, and spondylosis with myelopathy. The resident was documented as needing two-person assistance for bed mobility, turning, repositioning, and use of a bedpan, as well as being severely cognitively impaired and dependent on staff for most care. Despite these documented needs, the CNA provided care alone, without the required second staff member present. During the provision of care, the CNA attempted to turn the resident onto her left side and, while cleaning her, the resident rolled off the bed, resulting in a fall that caused a hematoma and laceration to the right side of the head. The incident required the resident to be transferred to the emergency room for further evaluation. Interviews with facility staff confirmed that the CNA did not request assistance as required by the care plan, and the Director of Nursing and Administrator both stated that staff are expected to follow care plans for residents needing extensive assistance.