Neglect Due to Failure to Follow Care Plan and Use of Personal Devices During Resident Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for all bed mobility and transfers due to multiple sclerosis and other conditions, was not provided care according to her established care plan. The care plan specified that two staff members were required for bed mobility and transfers, and the use of a Hoyer lift was indicated for transfers in and out of bed. Despite these requirements, a certified nurse aide performed bed mobility alone, without a second staff member present, and was using her personal cellphone and wearing earbuds during the provision of care. During the incident, the resident was being turned to her side by the aide when she slid from the bed onto her knees and then to the floor. The resident reported experiencing minor knee pain following the fall, and an x-ray was ordered to rule out fractures, which later returned negative. The resident also stated that no nursing staff came to assess her immediately after the fall, and that the aide was alone, distracted by her phone, and wearing earbuds at the time of the incident. The facility's internal investigation confirmed that the aide failed to follow the resident's care plan by not having a second staff member present and by being distracted with personal electronic devices during care. The incident was substantiated as neglect, as the resident's safety and care needs were not met according to established protocols and policies.