Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to follow a resident's established plan of care, resulting in a fall and injury. Specifically, a Geriatric Nursing Assistant (GNA) provided toileting care to a resident alone, despite the resident's care plan and GNA Kardex indicating a requirement for two-person assistance for both toileting and bed mobility. During this incident, the resident fell from the bed and sustained a laceration to the right side of the forehead, which required hospital evaluation and stitches. The deficiency was confirmed through medical record review, staff interviews, and facility investigation, which included a witness statement from the GNA admitting to not following the two-person assistance protocol. The resident involved had a documented need for two-person assistance for toileting and bed mobility as of a prior care plan update. The incident was reported by the resident's family, and subsequent review of progress notes and interviews with the Director of Nursing and former Administrator confirmed that the care plan was not followed at the time of the fall. The failure to adhere to the resident's care requirements directly led to the resident's injury.