Failure to Follow Care Plan for Transfer Assistance Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan by not providing the required assistance during transfers and toileting. The resident, who had diagnoses including dementia and was severely cognitively impaired, was assessed as needing partial staff assistance for bathing and toileting, and supervision for transfers. Despite this, on the day of the fall, documentation indicated that the resident was left to transfer and toilet independently, with no staff setup or physical help provided. This lack of assistance was confirmed by point of care records and an anonymous interview, which revealed that the resident's family observed the fall via a camera and had to notify staff. Further review of the resident's clinical record and interviews with staff confirmed that the care plan accurately reflected the resident's need for assistance, especially during periods of illness such as a urinary tract infection (UTI), which was present at the time of the incident. Previous nursing notes and event reports documented the resident's difficulty with transfers and increased confusion and falls associated with the UTI. Despite these documented needs and care plan directives, staff failed to provide the necessary support, resulting in a fall.