Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with a history of cerebral infarction resulting in right-sided weakness, severe cognitive impairment, and dependence on staff for bed mobility was not provided care according to their established care plan. The care plan, CNA Care Card, and Minimum Data Set (MDS) all specified that the resident required the assistance of two staff members for bed mobility, including turning and repositioning in bed. Despite these documented requirements, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets and reposition the resident alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and left the resident holding onto the bedrail while she moved to the other side of the bed. The fitted sheet being used was too small, causing the mattress to curl and resulting in the resident rolling out of bed and landing on their knees on the floor. The CNA then attempted to support the resident's upper body and called for help. The resident was subsequently assessed and found to have sustained bilateral distal femur fractures. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card prior to providing care, despite having received training and education on the importance of doing so. The CNA stated she was unfamiliar with the procedure for reviewing these documents and relied on verbal information from other staff. Other staff members confirmed that the CNA had been informed of the resident's need for two-person assistance but did not seek help when it was available. The failure to follow the care plan interventions directly led to the resident's fall, injuries, and subsequent death.