Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to consistently implement and follow a resident's care plan interventions, specifically regarding the required level of staff assistance during care. The resident, who had diagnoses including dementia and Parkinson's disease, was severely cognitively impaired and dependent on staff for all activities of daily living (ADLs), including bed mobility, dressing, toileting, and positioning. The care plan and Kardex clearly indicated that two staff members were required to assist with these tasks. On the evening of the incident, a certified nurse aide (CNA) provided incontinence care to the resident without another staff member present, despite the care plan's requirement for two-person assistance. The CNA positioned the resident on their side and briefly turned away to retrieve barrier cream, during which time the resident rolled off the bed and fell to the floor. The resident sustained a laceration to the head and a closed displaced fracture of the right femoral neck, requiring transfer to the hospital emergency department and subsequent admission. Interviews with staff revealed confusion and misunderstanding regarding the definition of bed mobility and the specific requirements for two-person assistance during care. The CNA involved believed that bed mobility only referred to boosting or small movements, not to positioning for personal care, and admitted to having provided care alone to the resident on previous occasions. Other staff confirmed that the care plan and Kardex specified two-person assistance for all care, and that this protocol was not followed at the time of the incident.