Failure to Follow Two-Person Repositioning Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to implement a comprehensive, person-centered care plan for a resident who was totally dependent on staff for all activities of daily living and required two-person assistance for repositioning. The resident, who was nonverbal, had a tracheostomy, and suffered from multiple complex medical conditions including anoxic brain injury, cirrhosis, and severe cognitive impairment, was care planned for two-person assistance during repositioning due to his total dependence and limited mobility. Despite this, a CNA attempted to reposition the resident alone, without the required assistance. During the solo repositioning attempt, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, an orbital fracture, and a sinus fracture. The incident was documented in the resident's progress notes and confirmed by interviews with staff, including the CNA involved, who admitted to not following the care plan and acknowledged being aware of the two-person requirement. The CNA did not request help, even though other staff were nearby and available. Interviews with nursing staff and facility leadership confirmed that the care plan and Kardex clearly indicated the need for two-person assistance for repositioning, and that all staff had been trained to access and follow these care plans. The failure to follow the established care plan directly led to the resident's fall and subsequent injuries, as confirmed by multiple staff interviews and record reviews.