Failure to Follow Care Plan Results in Resident Fall and Fracture
Penalty
Summary
A resident with a history of neck fracture and limited mobility was admitted to the facility and required a two-person assist for transfers during toileting, as documented in the care plan. Despite this, a CNA attempted to transfer the resident alone from the commode, resulting in the resident slipping and falling to the floor. The fall led to a fracture of the resident's right arm. The resident was cognitively intact at the time, with a BIMS score of 15 out of 15, and was aware of the care plan requirements for two-person assistance during transfers. Interviews and record reviews confirmed that the CNA did not follow the resident's individualized care plan, which specifically required two-person assistance for transfers and toileting. Facility staff, including the RCM and Administrator, acknowledged that the failure to adhere to the care plan directly led to the resident's fall and subsequent injury. The incident was substantiated by the facility's investigation and the resident's hospital discharge summary, which documented the right arm fracture resulting from the fall.