Failure to Prevent Accidents Due to Non-Compliance with Care Plans and Policies
Penalty
Summary
The facility failed to provide an environment free from accident hazards for residents at risk for falls by not following care-planned interventions and facility policies. For one resident with confusion, a history of falls, and a care plan requiring the use of hip protectors at all times, staff did not report the resident's refusal to wear the hip protectors after a shower. This lack of communication prevented other staff from implementing alternative interventions, and the resident subsequently experienced a fall resulting in a fractured hip. Another resident, who had a history of stroke and required assistance with activities of daily living, was being provided peri care when a nurse aide rolled the resident away from herself, contrary to facility policy and standard of care. This action resulted in the resident rolling off the bed, hitting her head, and sustaining a hematoma. The nurse aide involved had received training on proper bed mobility but did not follow the correct procedure during the incident. In both cases, the failure to adhere to established care plans and facility policies directly contributed to the residents' injuries. The incidents were confirmed through review of clinical records, staff interviews, and facility investigation reports, which documented the sequence of events and the specific lapses in following required protocols.