Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
Facility staff failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by the fall of a resident during personal care. The resident, who had severe cognitive impairment, impaired mobility, and was dependent on staff for all activities of daily living, was care planned to require two staff for bed mobility and personal care. However, on the day of the incident, only one staff member was actively providing care, while another staff member was present in the room but assisting a different resident. The staff member providing care turned away from the resident to retrieve supplies, during which time the resident rolled out of bed and sustained a head laceration and a neck fracture. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements. The nurse aide providing care was not aware that two staff were required for personal care according to the care plan and typically provided care alone. Other staff members, including CNAs, LPNs, and the DON, confirmed that care should be provided according to the care plan and that two staff should be present and actively participating when indicated. Staff also stated that all necessary supplies should be within reach before starting care, and if additional items are needed, the resident should be safely positioned and not left unattended. Record review showed that the facility did not have a specific policy regarding falls or accidents, and there was no process in place to ensure that staff were consistently aware of and following the care planned needs of each resident. The lack of communication and implementation of the care plan directly contributed to the resident's fall and subsequent injuries. The incident was witnessed, and documentation confirmed the resident's injuries and the sequence of events leading to the fall.