Failure to Honor Resident Refusal and Ensure Safety Leads to Fall and Injury
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a history of refusal of care and at moderate risk for falls sustained a head injury after a fall. The incident took place when a CNA attempted to enter the resident's room despite the resident's refusal, resulting in the resident falling backward and sustaining a laceration to the back of the head. The resident was subsequently sent to the hospital for evaluation. The resident's care plan documented severe cognitive impairment, destructive and intrusive behaviors, and a risk for falls, with interventions to redirect negative behaviors and monitor for changes in gait status. The CNA involved in the incident reported attempting to check on the resident, who persistently refused and tried to shut the door. The CNA continued to insist on entering, leading to the resident losing balance and falling. Statements from other staff confirmed that the resident was particular about care and could become upset if things were not done according to their preferences. Staff interviews indicated that training had been provided on respecting residents' rights, including the right to refuse care and the importance of not violating privacy, especially for those with cognitive impairments. Facility policies reviewed by the surveyor emphasized treating residents with dignity and respect, honoring refusals of care, and implementing fall prevention interventions based on risk assessments. Despite these policies and staff training, the CNA's actions did not align with established protocols, directly resulting in the resident's fall and injury. The deficiency was identified through observation, interviews, and review of medical records and facility documentation.