Failure to Follow Care Plans and Provide Adequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff followed resident care plans and provided adequate supervision and assistance to prevent accidents for three residents. In multiple instances, staff did not adhere to the required two-person assist for bed mobility and transfers, as documented in the residents' care plans. For one resident with severe cognitive impairment and total dependence on staff for bed mobility, two separate falls occurred during care when only one staff member was present, resulting in injuries that required emergency room evaluation. Staff involved in these incidents acknowledged they were aware of the two-person assist requirement but did not follow it. Another resident, who required extensive two-person assistance with a gait belt for transfers due to physical impairments and moderate fall risk, reported being transferred by a single CNA who lifted the resident by the biceps without a gait belt. This action was not in accordance with the resident's care plan and caused the resident pain. The facility's own investigation confirmed that the care plan was not followed during this transfer. A third resident, dependent on staff for all mobility and transfers and requiring a mechanical lift, was found with a large bruise on the upper extremity. The facility determined the injury likely occurred when staff improperly grabbed the resident's arm to assist with rolling in bed or due to poor positioning in a wheelchair. The required evaluation by physical therapy for wheelchair positioning was not completed, and staff did not receive documented re-education on proper handling techniques as indicated in the facility's incident report. In all cases, the facility was unable to provide documentation that staff re-education or corrective interventions were completed as required by their own policies.