Failure to Follow Care Plan and Incident Reporting Leads to Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to implement care plan interventions and thoroughly document or investigate a fall for a resident with multiple diagnoses, including cerebral palsy, Alzheimer's disease, dementia, osteoporosis, and arthritis. The resident's care guide had been updated to require two-person assistance with a gait belt for toileting, but this was not followed. On the evening of the incident, a CNA assisted the resident alone in the bathroom, did not check the care guide beforehand, and subsequently lowered the resident to the floor when she began to lose her balance. The CNA was unaware of the updated care plan requirement for two-person assistance. Following the incident, the resident did not initially complain of pain, and the LPN who responded did not complete an incident report at the time. Over the next several days, the resident began to complain of increasing pain in her right leg, which was noted by multiple staff members during care. The pain and decreased mobility led to the use of a mechanical lift for transfers, which was unusual for the resident. Despite these complaints, there was no immediate documentation or investigation linking the pain to the earlier incident in the bathroom. It was only after the resident's pain persisted and an X-ray was ordered that a right fibula fracture was identified. A review of facility records and camera footage later confirmed that the resident had been lowered to the floor by a single CNA, contrary to the care plan. The incident report was not completed until after the fracture was discovered, and the initial investigation did not identify the fall as the cause of the injury. The facility's policies required staff to check care guides before providing care and to complete incident reports promptly when a resident falls or sustains an injury, but these procedures were not followed in this case.