Failure to Follow Care Plans Results in Resident Falls Due to Neglect
Penalty
Summary
Three residents experienced neglect due to staff failing to follow established care plans and facility policies. One resident with severe cognitive impairment and a history of dementia was not offered toileting opportunities every two hours as required by their care plan. Documentation showed that the resident was only offered toileting once per shift, and there was no evidence of two-hourly toileting prior to the incident. This failure led to the resident attempting to toilet themselves, resulting in a fall and bruising. Another resident, also with severe cognitive impairment and multiple diagnoses including vascular dementia and Alzheimer's disease, required two-person assistance for transfers according to their care plan. Despite this, a Certified Nurse Aide attempted to transfer the resident alone, which resulted in the resident being lowered to the floor due to non-compliance with directions and improper body mechanics. The care plan specifically indicated the need for two-person assistance with a mechanical lift, which was not followed. A third resident, diagnosed with Parkinson's disease and dementia, was at high risk for falls and required a bed alarm as part of their fall prevention interventions. After being put back to bed by staff, the bed alarm was not activated as required by the care plan. The resident was subsequently found on the floor next to their bed, and documentation confirmed that the bed alarm was not in place at the time of the fall. In all three cases, the failure to adhere to individualized care plans directly contributed to resident falls.