Failure to Follow Care Plan Results in Resident Fall During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracranial hemorrhage, diabetes mellitus with hyperglycemia, polyneuropathy, and morbid obesity experienced a fall during a transfer for weighing. The resident was assessed as requiring substantial/maximal assistance from two staff members, a gait belt, and a front wheeled walker for all transfers, as documented in the care plan and staff assignment sheet. The care plan also specified that the weight chair should be placed against the wall to prevent it from moving during transfers. Despite these documented requirements, only one CNA assisted the resident during the transfer to the weight chair, and the CNA was unaware that two staff were required for this task. As a result, when the resident stood from the weight chair, the chair moved, causing the resident to sit onto the ground. The incident was documented in the progress notes, and it was confirmed through interviews that the care plan was not followed at the time of the fall.