Failure to Provide Required Supervision and Assistance During Resident Care
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, and moderately impaired cognition sustained a fall resulting in a nasal fracture during morning care. The resident's care plan required a two-person physical assist for bed mobility due to their condition, but Certified Nurse Aide (CNA) #1 provided care alone. CNA #1 did not log into the electronic medical record to review the resident's current care needs before providing care, as required by facility policy and orientation training. During the incident, the resident was turned and rolled out of bed, falling to the floor and sustaining injuries that required hospital transfer. Facility documentation and interviews confirmed that CNA #1 was not familiar with the updated care plan and did not follow the required protocol for checking care instructions prior to providing hands-on care. The charge nurse and Director of Nursing both stated that staff are expected to review electronic records for each resident's care requirements before beginning care. The failure to provide the required level of assistance and to follow established procedures directly led to the resident's fall and injury.