Failure to Follow Care Plan and Report Incident Results in Resident Injury
Penalty
Summary
A deficiency occurred when two certified nurse aides (CNAs) failed to follow a resident's care plan, which required the use of a full-body mechanical lift with two staff for all transfers due to the resident's inability to bear weight and significant cognitive impairment. Instead, the CNAs attempted a stand and pivot transfer from a shower chair to a wheelchair, during which the resident's knees buckled and she was lowered to the floor. The CNAs then attempted to lift the resident from the floor without the mechanical lift, were unsuccessful, and subsequently used the mechanical lift to transfer her to the wheelchair. The incident was not reported to the licensed nurse on duty at the time, and the CNAs only reported that the resident bent her leg and complained of pain during the transfer. The resident, who had diagnoses including age-related osteoporosis and severe cognitive impairment, was dependent on staff for all activities of daily living and was at high risk for falls. Following the unreported incident, the resident began to complain of leg pain, and subsequent assessments by nursing staff revealed swelling and abnormal positioning of the left knee. X-rays later confirmed fractures in both the left femur and right fibula. The delay in accurate reporting and assessment resulted in a delay in appropriate medical intervention and follow-up care for the resident. Multiple staff interviews and witness statements confirmed that the CNAs were aware they had not followed the care plan and actively chose not to report the incident to nursing staff or administration, with one CNA instructing the other to keep the incident secret. Other staff who later learned of the incident also delayed reporting it to administration. The facility's policies required immediate reporting of such events and adherence to care plans, but these were not followed, resulting in neglect and immediate jeopardy to the resident.