Failure to Follow Care Plan Results in Resident Shoulder Dislocation
Penalty
Summary
A deficiency occurred when staff failed to provide care in accordance with a resident's care plan, resulting in a left shoulder dislocation. The resident was severely cognitively impaired, nonverbal, and fully dependent on staff for all activities of daily living due to Alzheimer's disease. The care plan specified that two staff members were required to safely reposition the resident in bed. However, a CNA reported providing incontinence care and repositioning the resident alone on multiple occasions during a night shift, contrary to the care plan instructions. The incident was discovered when the CNA noticed bruising and swelling on the resident's left shoulder while dressing her. The CNA reported the finding to the RN, who assessed the resident and found the area to be purple and warm to the touch. The hospice nurse was notified and, upon assessment, found the shoulder to be floppy and unstable, prompting an X-ray order. The X-ray revealed a dislocated left shoulder with a possible glenoid fracture, and the resident was subsequently sent to the hospital for evaluation. Interviews with facility staff confirmed that the resident was unable to move independently and had no history of falls or injuries during the relevant period. The nurse practitioner and hospice nurse both stated that the injury could not have occurred spontaneously and must have resulted from trauma or force. The DON confirmed that staff are expected to follow the care plan, which required two staff for repositioning, and that this protocol was not followed in this case.