Failure to Follow Care Plan for Resident Transfers and Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident with severe cognitive impairment, Alzheimer's disease, osteoporosis, and a history of fractures. The resident was care planned to require two-person physical assistance for transfers, bed mobility, and incontinent care. Despite this, the CNA performed a one-person transfer from wheelchair to bed and provided one-person assistance during incontinent care on multiple occasions. The CNA was unaware that the resident's assistance level had changed and had been providing one-person assistance since returning from leave, without checking the current care plan or Kardex. Following these transfers and care episodes, the resident began to complain of pain in her left leg, which was initially not accompanied by visible abnormalities. Over the course of the night and early morning, the resident's pain increased and discoloration developed on her left lower leg. Subsequent assessments and imaging revealed acute proximal and mid left lower leg fractures. The CNA stated she did not use a gait belt during the transfer and was not aware of the updated assistance requirements, citing issues with accessing the electronic care plan system. Nursing staff and the DON confirmed that the resident required two-person assistance and that the CNA did not follow the care plan as required. Interviews with nursing staff revealed a lack of clear communication and monitoring regarding changes in residents' assistance levels. The charge nurse and other staff assumed the CNA was aware of the resident's needs and did not verify that the correct level of assistance was being provided. The facility's policy and training documentation did not clearly specify the requirement to follow the care plan, and there was no written evidence of prior in-service training for the CNA on this topic. The failure to provide the appropriate level of assistance as outlined in the care plan resulted in the resident sustaining significant injuries.