Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to follow the comprehensive care plan for a resident who required two-person assistance for toileting and other activities of daily living. The care plan, based on the resident's medical history of hemiplegia, hemiparesis, muscle weakness, and other significant diagnoses, specified that two staff members were needed for toileting, transfers, bathing, bed mobility, and dressing due to the resident's inability to assist with their own care and severe physical limitations. Despite these documented needs and interventions, a Certified Nursing Assistant (CNA) provided care alone, without the required second staff member. As a result of this failure to follow the care plan, the resident fell out of bed while being cared for by a single CNA, sustaining a left femoral neck fracture and a left frontal scalp hematoma. Staff interviews confirmed that the care plan required two people for all care activities involving the resident, and that assistance could have been obtained from another CNA or nurse if needed. The incident was identified as actual harm to the resident due to noncompliance with the established care plan.