Failure to Follow and Communicate Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's plan of care was followed and properly communicated to all staff, resulting in a fall that caused head trauma and a laceration requiring hospital transfer. The resident involved had significant medical conditions, including Parkinson's disease, hemiplegia, muscle wasting, and dementia, and was assessed as having severe cognitive impairment and total dependence on staff for care. The care plan specified that the resident required two-person assistance for all activities of daily living, including turning and repositioning, due to impaired upper and lower extremities and inability to roll independently. On the day of the incident, a CNA was providing incontinence care and attempted to turn the resident without a second staff member present, contrary to the care plan requirements. The CNA did not review the plan of care or receive a report from the previous shift regarding the resident's assistance needs. During the care, the resident rolled out of bed and sustained a head injury. The incident report and staff interviews confirmed that the resident was found on the floor with active bleeding and was transferred to the hospital for further evaluation and treatment. Further review revealed discrepancies between the facility's investigation and the documented care plan. While the investigation concluded that the CNA followed protocol, the care plan and MDS assessment clearly indicated the resident was unable to assist with turning and required two-person assistance. The CNA later acknowledged not reviewing the care plan prior to providing care. The facility was unable to provide a bedrail assessment, and staff interviews confirmed the resident's total dependence and immobility. The failure to follow and communicate the care plan interventions directly led to the resident's fall and injury.