Failure to Follow Care Plan for Dependent Resident Results in Fatal Fall
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was totally dependent on staff for activities of daily living (ADL) care, including bed mobility and transfers. The resident had significant medical needs, including contractures in multiple joints, blindness, immobility, impaired cognition, muscle weakness, and an inability to care for herself. The resident's care plan and Minimum Data Set (MDS) assessment specified that she required two-person assistance for bed mobility, bathing, and transfers. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care to the resident with only one-person assistance while giving a bed bath and changing linens. During this process, the resident rolled out of bed, fell to the floor, and sustained a head injury. The CNA called a Registered Nurse (RN), who assessed the resident and found a laceration on her head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. Interviews with staff revealed inconsistencies in understanding and following the plan of care, with some staff relying on memory or assumptions rather than verifying the required level of assistance in the care plan. Some staff believed that only one person was needed for certain in-bed care tasks, despite the care plan's requirement for two-person assistance. The failure to adhere to the care plan directly resulted in the resident's fall and subsequent death.
Removal Plan
- R1 is no longer at the facility.
- Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care and the support staff needed for ADL care by the DON. Validation of staff education and competency was completed by the DON.
- In-service education was initiated for all nursing staff regarding adhering to the plan of care and the support staff needed for ADL care. Education included how to access the level of care required on the POCs, bed mobility, plan of care, and residents' alerts. DON, ADON, and nurse managers provided education to all RN, LPNs, CNAs, CMAs, and RAI coordinator. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
- 100% audits of the resident plan of care and ADL plan of care were completed to reflect that all residents who require assistance with bed mobility were accurate. Audit was completed by Don, Adon, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
- The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
- Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and Charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1, then monthly for two months, and/or when compliance is achieved or maintained.
- An Adhoc Quality Assurance Process Improvement (QAPI) meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F656. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. The Administrator, DON, Medical Director, Director of Regulatory and Quality Services, ADON, Resident Care Coordinator, Social Service Director, Activity Director, Healthcare Navigator, Human Resource partner, Rehab Director, Schedule Coordinator, and housekeeping supervisor were in attendance.
- All corrective actions were completed. The facility alleges that the IJ was removed.