Failure to Follow Care Plan Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with significant physical disabilities, morbid obesity, and moderate cognitive impairment was care planned to require a two-person assist for bed mobility and activities of daily living. The resident was totally dependent on staff for movement and unable to reposition or turn independently. On the night of the incident, a Certified Nurse Aide (CNA) was unable to locate another staff member to assist with the resident's care, despite waiting and searching for approximately 45 minutes. The CNA proceeded to provide bed mobility care alone, contrary to the resident's care plan, and subsequently found the resident on the floor after leaving and returning to the room. Upon assessment by a nurse, the resident was found with a skin tear to the left elbow, hematomas to the left knee and left side of the forehead, and complaints of pain. Neuro checks were initiated, and the physician was notified. X-rays were ordered and later revealed fractures of both femurs. The resident was not transferred to the hospital until several hours after the fall, despite ongoing pain and abnormal X-ray findings. There was a lack of documentation regarding the resident's pain and status updates between the time of the fall and the transfer to the hospital. Interviews with staff confirmed that the CNA was aware of the two-person assist requirement but proceeded alone due to lack of available help. Other staff members stated that the resident was unable to move himself in bed or reach for objects independently. The death certificate indicated that the resident died from blunt force trauma to the right thigh, with the manner of death listed as an accident resulting from a fall at the facility.