Failure to Follow Care Plan Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan, which required two staff members to assist with incontinence care. Despite this intervention being clearly documented in the care plan, a nursing assistant provided care alone, resulting in the resident rolling out of bed and falling. The incident was witnessed, and the resident subsequently complained of severe pain. The resident involved had significant medical needs, including hemiplegia and hemiparesis following a stroke, dependence on a ventilator, and use of both a tracheostomy and gastrostomy. The resident was assessed as totally dependent on staff for all activities of daily living. As a direct result of the failure to implement the care plan, the resident sustained fractures to the left distal tibia and fibula. The facility was unable to provide evidence that staff followed the care plan as required.