Failure to Implement Comprehensive Care Plan for Resident with Grabbing Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific interventions to address a resident's known grabbing behaviors, particularly in relation to the use of side rails. The resident had a history of dementia with behavioral disturbances, severely impaired cognition, and was dependent on staff for all activities of daily living, including bed mobility and transfers. The care plan identified the resident's potential for aggressive behaviors and included general interventions such as monitoring behaviors and redirecting agitation, but did not include targeted measures to prevent injury from grabbing side rails. Despite multiple staff members documenting and reporting that the resident consistently grabbed side rails and exhibited sudden, resistive movements during care and transfers, the care plan lacked interventions to mitigate the risk of injury from these behaviors. Staff interviews revealed that, in practice, some staff used pillows to position the resident's arms or to prevent grabbing, but these actions were not formalized in the care plan. The facility's documentation and investigation confirmed that the resident's grabbing behaviors were well known prior to the incident. An incident occurred in which the resident sustained a nondisplaced fracture of the right hand, with evidence indicating the injury was caused by the resident placing their hand in the lower opening of the side rail. The facility's summary and staff interviews confirmed that the discoloration and injury aligned with the side rail, and that the side rails were subsequently discontinued and replaced with a perimeter mattress. However, prior to the injury, the care plan did not include interventions such as padding or removing the side rails to prevent injury, despite the resident's established risk and staff awareness of the behaviors.