Failure to Follow Care Plans Results in Resident Harm
Penalty
Summary
The facility failed to protect two residents from neglect during care, resulting in actual harm. In the first incident, a resident with orders requiring transfer assistance from two staff members and a wheeled walker, and who was assessed as fully dependent for mobility, was transferred by a single CNA. During the transfer from a shower chair to a wheelchair, towels were placed under the resident's feet to keep them dry, but the resident stepped off the towels and slipped. The CNA attempted to lower the resident to the floor, but the resident sustained a left femur fracture. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member, contrary to the resident's care plan and physician's orders. In the second incident, another resident, who was dependent on two staff for bed mobility due to cognitive impairment and physical limitations, was being rolled in bed by a single CNA during morning care. The CNA rolled the resident too far, causing the resident to fall out of bed from a height of approximately 18 inches. The resident sustained a laceration above the right eyebrow and forehead, which required sutures and further medical evaluation. The care plan, Kardex, and task documentation all indicated that two staff were required for bed mobility, but this was not followed. Both incidents were confirmed through facility documentation, clinical records, and staff interviews. The Director of Nursing and Nursing Home Administrator acknowledged that in both cases, staff failed to follow established care plans and physician orders requiring two-person assistance for transfers and bed mobility. These failures resulted in actual harm to the residents, including a femur fracture and a laceration requiring stitches.