Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to implement person-centered care planned interventions for a resident who was dependent on staff for all aspects of personal care, including bathing and bed mobility. The resident, who had diagnoses such as absolute glaucoma, muscle weakness, difficulty walking, and required total assistance, had a care plan specifying that two staff members were required for all care. Despite this, a single CNA provided a bed bath without assistance, during which the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The care plan and MDS documentation clearly indicated the need for two-person assistance, but this intervention was not followed. Interviews with staff confirmed that the resident was always cared for by one CNA, despite the care plan's directive. The CNA involved stated that she never received help from other staff members when providing care to this resident. The incident resulted in the resident being transported to the hospital and not returning to the facility. Facility policy required staff to follow care planned interventions and to implement measures to prevent falls, but these were not adhered to in this case.