Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions related to fall prevention for a resident with significant medical and cognitive impairments. The resident had a history of hemiplegia, contractures in both knees, seizures, dementia with behavioral disturbances, and was dependent on staff for all activities of daily living (ADL), including transfers, which required assistance from two or more staff members. The care plan specifically identified the resident as being at risk for falls and required a two-person assist for ADL care due to extensive assistance needs and confusion, including delusions about being able to walk. Despite these documented needs and interventions, only one CNA provided incontinent care, during which the resident rolled out of bed and fell to the floor. As a result, the resident sustained a distal fracture of the left femur and a fracture of the lower end of the right tibia. Review of facility policy and interviews confirmed that care plans were not consistently updated or followed, and the required two-person assist was not provided at the time of the incident.