Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility and repositioning, was not provided care according to their established care plan. The resident's care plan and task orders clearly indicated that two staff members were required to assist with rolling and repositioning in bed. Despite this, an agency CNA attempted to roll the resident independently during morning care, without seeking assistance or following the documented care instructions. During the attempted repositioning, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The resident was found to be in significant pain and was later transferred to the hospital, where a CT scan revealed a small, acute bilateral intraventricular hemorrhage. The resident's non-verbal status prevented them from providing any account of the incident. Staff interviews confirmed that the resident always required two-person assistance for bed mobility, and this information was accessible in the task orders. The agency CNA involved acknowledged in a written statement that they were unaware of the resident's stiffness and did not receive information about the need for two-person assistance. The incident was witnessed by another CNA, who found the resident partially out of bed and bleeding. The facility's investigation confirmed that the agency CNA did not follow the care plan or task orders, resulting in actual harm to the resident.