Failure to Follow Care Plan Results in Resident Falls and Injury
Penalty
Summary
Facility staff failed to follow the individualized care plan for a resident with multiple complex medical conditions, including a history of stroke, type II diabetes, PEG tube, low vision, obesity, hemiplegia, and respiratory failure. The care plan specified that the resident required assistance from two staff members for bed mobility, the bed should be kept in the lowest position, a body pillow should be used during repositioning, and that staff, family, and caregivers should be notified of any new skin breakdown. Despite these directives, the resident was found on two separate occasions on the floor beside the bed, having sustained abrasions to the knees. In both incidents, the bed was not in the lowest position as required by the care plan. Staff interviews confirmed that the care plan interventions were not consistently followed. On one occasion, an LPN was not informed of the resident's abrasion or the new intervention requiring two-hour staff checks. A CNA also confirmed that the bed was not in the lowest position at the time of the fall and acknowledged that staff should have adhered to the care plan. The administrator confirmed the expectation that staff follow each resident's care plan, but the documented events and staff statements indicate that this did not occur for the resident in question.