Failure to Implement Care Plan Interventions for Transfers and Fall Prevention
Penalty
Summary
The facility failed to implement and follow individualized care plan interventions for two residents, resulting in a significant injury for one and failure to prevent potential falls for another. For one resident with moderate cognitive impairment and a history of repeated falls, the care plan included specific interventions such as pinning the top blankets to the fitted sheet to prevent entanglement and offering bathroom assistance at designated times. Multiple observations revealed that the top covers were not pinned as required, and staff interviews confirmed a lack of awareness regarding this intervention. This failure to implement the care plan intervention was directly observed on several occasions and acknowledged by both nursing assistants and an LPN. For another resident with cirrhosis, muscle weakness, generalized edema, and diabetes, the care plan specified that transfers from bed to wheelchair required two staff members and the use of a slide board or Hoyer lift. Despite this, the resident was transferred by only one staff member, a Certified Medication Aide, without the use of a gait belt or slide board. The aide reported that the resident claimed to transfer independently and instructed the aide on how to position the wheelchair. During the transfer, the resident sustained a laceration to the left lower leg after hitting the wheelchair pedal bracket, requiring hospital transport and stitches. Interviews with staff and the resident confirmed that only one staff member was present during the transfer, contrary to the care plan requirements. Facility policies reviewed indicated that individualized care plans are to be developed and interventions provided according to professional standards and the resident's needs. The failure to follow these care plans and ensure staff awareness of required interventions led to a significant injury and the lack of fall prevention measures for the residents involved. The deficiencies were identified through observation, record review, and staff interviews.