Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
Facility staff failed to implement the care plan for one resident who was assessed as cognitively intact but completely dependent on staff for bed mobility following a recent hospitalization. The resident's care plan and Kardex both specified a two-person assist for bed mobility and incontinence care, with the use of a draw sheet or lift sheet for turning and repositioning. On the morning in question, only one CNA provided incontinence care, contrary to the care plan requirements. During this care, the CNA pulled the draw sheet, causing the resident to fall from the bed onto her knees, resulting in significant knee pain. The resident confirmed that sometimes two CNAs are present for care, but at other times only one is available. Staff interviews revealed that the CNA was aware of the two-person assist requirement but proceeded alone because other staff were occupied. The LPN confirmed that staff are informed of care requirements via the Kardex and that the charge nurse is responsible for ensuring care plans are followed. Facility documentation and policy review further supported that individualized care plans are to be developed and implemented to meet each resident's needs. The failure to follow the care plan directly led to the resident's fall and subsequent pain.