Failure to Follow Care Plans and Safety Protocols During Resident Transfers and Bed Mobility
Penalty
Summary
The facility failed to follow care plans and implement appropriate safety precautions for two residents, resulting in deficiencies related to accident hazards and supervision. In the first case, a resident with multiple diagnoses including lumbar spinal cord lesion, morbid obesity, and chronic pain, was care planned for two-person assist with bed mobility and had interventions for fall risk. Despite this, a CNA provided care alone, turned the resident to the side, and left the resident unattended while retrieving a towel. The resident subsequently fell from the bed, sustaining multiple injuries including bruising, skin tears, and bleeding from the mouth. Documentation at the time of the incident was incomplete, with no progress note from the night shift nurse, and the incident was only recorded in a separate risk management report, not in the resident's medical record. In the second case, another resident with right hemiplegia and moderate cognitive impairment required total care and was care planned for two-person Hoyer lift transfers. During a transfer, a CNA allowed the resident's representative, who had not been trained in Hoyer lift use, to assist with the transfer. During this process, the Hoyer lift pad swung and the holder grazed the resident's forehead. The incident was reported, and neuro checks were initiated, but there was no evidence that the representative had received any education or training on safe transfer procedures, as required by the care plan and facility policy. Both incidents demonstrate failures to adhere to established care plans and protocols for resident safety, including the requirement for two-person assistance during bed mobility and transfers, and ensuring that only trained personnel participate in resident care activities. The lack of proper documentation and deviation from care plans directly contributed to the occurrence of accidents and potential harm to the residents involved.