Neglect Resulting in Resident Fall and Injury Due to Failure to Follow Care Plan
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide necessary services to a resident with significant mobility limitations, resulting in neglect and physical harm. The resident, who had a history of stroke with right-side hemiplegia, an above-the-knee amputation, muscle wasting, dementia, and was assessed as totally dependent on staff for personal hygiene and bed mobility, was left unattended in a raised bed. The CNA left the resident alone to change gloves, during which time the resident fell from the elevated bed onto the floor. The resident sustained a closed fracture of the right femur and a contusion to the left shoulder as a result of the fall. The resident reported feeling scared and traumatized by the event, as documented in a trauma screen and social work notes. The care plan for the resident specified the need for substantial or maximal assistance, including two-person assistance for bed mobility and personal care, which was not followed at the time of the incident. Interviews with staff confirmed that the resident required two-person assistance and that it was not acceptable to leave such a resident unattended, especially with the bed in a high position and without bedrails in place. Further review of facility policies indicated that staff were trained and expected to follow individualized care plans and provide adequate supervision to prevent neglect and physical harm. The CNA involved was suspended and subsequently terminated for violation of safety rules and failure to follow the care plan. There were also unsubstantiated reports from staff regarding possible impairment of the CNA while on duty. The incident was reported as neglect due to the failure to provide the required level of assistance and supervision, directly resulting in the resident's injury.