Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as requiring two staff members for repositioning and turning in bed due to paraplegia, seizure disorder, respiratory failure, and other comorbidities, was repositioned by a single CNA. The resident rolled off the bed during this process, resulting in three fractures to the hip, knee, and back, and required increased pain management, including narcotic medications. The resident's care plan and Kardex both specified the need for two-person assistance, but this was not followed. Facility records and interviews revealed that the CNA involved provided care independently, contrary to the resident's care plan. The facility's investigation confirmed that the fall and resulting injuries could have been prevented if the care plan had been followed. Additionally, review of staff training records showed that several CNAs had not completed required Kardex Protocol training prior to returning to work, with only 75% of CNA staff having completed the training. Staff interviews indicated issues with training reminders and access, contributing to inadequate education on following care plans.