Failure to Investigate and Follow Care Plan for Dependent Resident After Fall
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation to identify the causal factors of a fall involving a severely cognitively impaired resident. The resident, who was totally dependent on staff for care due to conditions including Parkinson's disease, hemiplegia, muscle wasting, and dementia, was found lying on the floor in a pool of blood with a hematoma and laceration to the head, requiring emergent transfer to the hospital. The resident's care plan and MDS assessment indicated a need for two-person physical assistance with all care and transfers, and that the resident was unable to turn or roll independently. Despite these documented care requirements, the investigation concluded that the resident rolled out of bed during an incontinent and linen change. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's care plan. The CNA involved in the incident did not check the care plan prior to providing care and was unaware that two-person assistance was required. Additionally, the CNA did not receive a report from the previous shift about the resident's care needs. The DON was unable to comment on the plan of care at the time of the survey and had not reviewed the MDS coding related to the resident's needs. Documentation and interviews further showed that the facility did not provide statements from all involved staff and could not produce evidence of in-service education for the CNA involved in the fall. The investigation was closed without a clear identification of the root cause, and the facility was unable to comment on the plan of care required for the resident, despite the assessment indicating the need for two-person assistance. This lack of thorough investigation and failure to ensure staff followed the resident's care plan led to the deficiency.