Failure to Follow Care Plan for Two-Person Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to follow its own comprehensive care plan policy for a resident with significant medical and cognitive impairments. The resident, who was admitted with multiple diagnoses including Parkinson's Disease, Diabetes, Morbid Obesity, Atrial Fibrillation, Epilepsy, Congestive Heart Failure, Chronic Kidney Disease Stage 3, tracheostomy and gastrostomy status, and dependence on a respirator ventilator, was assessed as requiring two-person assistance for bed mobility and transfers, as well as mechanical lift use. The care plan and nursing admission evaluation both documented the need for two-person assistance due to the resident's inability to move independently, cognitive impairment, and high risk for falls. Despite these documented needs, a CNA provided care to the resident without the required two-person assistance. The CNA repositioned the resident alone during a shift and did not seek help from other staff, stating she was unaware of the two-person assist requirement. As a result, the resident, who was severely cognitively impaired and nonmobile, fell from the bed to the floor when repositioned by only one staff member. The DON confirmed that the care plan was not followed and that the CNA should have requested assistance.