Failure to Provide Adequate Supervision and Individualized Care Plan During Resident ADL Care
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, muscle wasting, and abnormal gait, who was totally dependent on staff for activities of daily living (ADLs), fell from bed while receiving care. The resident was observed with swelling and discoloration on the right cheek and a dime-sized abrasion on the right elbow. The resident was unable to move the right upper and lower extremities and had slurred speech but could communicate with simple words. The fall happened while a CNA was providing peri-care and turning the resident, during which the resident's weight shifted and resulted in a fall from the bed to the floor. Record review showed that the resident required maximum assistance with transfers and bed mobility and was dependent on staff for all ADLs. The care plan for the resident indicated the need for a safe and hazard-free environment but did not specify the type or number of staff assistance required during care. Interviews with staff revealed that the resident was not positioned in the center of the bed before being turned, and only one CNA was present during the incident. Staff acknowledged that the resident was totally dependent and should not have been turned alone, and that assistance should have been requested to ensure safety. Facility policies required periodic assessment of residents' needs for ADL care, monitoring and modifying care plans as necessary, and ongoing training on patient safety and fall prevention. However, the interventions in the resident's care plan were not individualized to specify the necessary assistance, and staff did not follow procedures to ensure the resident's safety during care, directly leading to the fall and resulting injuries.