Failure to Implement and Communicate Resident Care Plan Leads to Fall with Injury
Penalty
Summary
The facility failed to implement a resident's care plan for a resident with multiple complex medical needs, including Multiple Sclerosis, muscle weakness, and a Stage III pressure ulcer. The resident was dependent on staff for transfers, bed mobility, and personal hygiene, requiring total assistance by two staff members and the use of a mechanical lift. Despite these documented needs, a CNA assigned as a float was not adequately informed about the resident's care requirements and did not review the care plan or Kardex. The CNA relied on verbal instructions from other CNAs and was unaware of the resident's diagnosis or specific care needs. On the day of the incident, the CNA turned the resident alone, left the resident positioned on their side, and exited the room to get a nurse, leaving the bed in a raised position. Upon returning, the resident was found on the floor, having fallen from the bed. Interviews revealed that the CNA had never accessed the care plan or Kardex and believed only nurses had access to these documents. There was inconsistency in the information provided to the CNA by nursing staff, and the CNA did not have a clear understanding of the resident's needs or the proper procedures for safe repositioning and transfer. The administrator acknowledged that staff were not following care plans, which directly contributed to the resident's fall and injury.