Failure to Follow Two-Person Assist Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility and positioning, was repositioned in bed by a single CNA without the required assistance of a second staff member. The resident's care plan and CNA Care Card both clearly indicated the need for two staff members to assist with bed mobility and positioning. Despite this, the CNA proceeded alone, resulting in the resident sliding off the bed and falling to the floor. The CNA involved stated that she was not familiar with the resident's care needs and did not check the Care Card prior to providing care. She had previously cared for the resident on a different unit but was unaware of the two-person assist requirement. Although another CNA was present in the room, she was attending to a different resident and did not assist or witness the fall. The facility's policy required all staff to be familiar with and follow the care plan, and the Care Cards were accessible at the nursing station for staff reference. Interviews with facility staff, including the unit manager and DON, confirmed that the resident was completely dependent on staff and that the Care Card accurately reflected the need for two-person assistance. The incident was witnessed and reported, and the CNA acknowledged not reviewing the Care Card before providing care, which directly led to the failure to implement the care plan as required.