Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, legal blindness, and a history of chronic conditions including epilepsy and normal pressure hydrocephalus, was not provided the required level of assistance during activities of daily living (ADL) care. The resident's care plan specified the need for two-person assistance for ADL care due to limited mobility and other health conditions. Despite this, a Licensed Nursing Assistant (LNA) provided care alone, attempting to change bed linens and reposition the resident without additional help. During this unsupervised care, the LNA rolled the resident to the side of the bed, resulting in the resident falling to the floor. The incident led to the resident experiencing pain and being hospitalized for a fractured hip and pelvic injuries. Interviews confirmed that the care plan intervention requiring two-person assistance was not followed at the time of the incident, and the unit manager acknowledged that adherence to the care plan would have prevented the fall.