Failure to Follow Care Plan Results in Resident Injury Due to Inadequate Assistance
Penalty
Summary
A certified nursing assistant (CNA) failed to follow the care plan for a male resident with multiple diagnoses, including cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff, requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this, the CNA attempted to provide in-bed care alone, turned the resident onto his side, and the resident subsequently rolled off the bed, sustaining a laceration to the left forehead that required sutures and hospital evaluation. The CNA admitted to not checking the Kardex to confirm the required level of assistance and stated she had always provided care to this resident alone, unaware of the two-person assist requirement. The care plan and Kardex both indicated the need for two-person assistance, but this was overlooked. The incident was witnessed by another staff member, and the resident was found on the floor with active bleeding. The nurse on duty confirmed that the CNA did not request help and that the care plan clearly required two-person assistance for bed mobility and transfers. Interviews with facility leadership revealed inconsistent understanding of the resident's care requirements, with the DON initially believing the resident was a one-person assist and only learning of the two-person requirement after the incident. The administrator did not conduct an independent investigation and relied on the DON's report, attributing the incident to a possible typo in the care plan and oversight by the CNA. The failure to follow the care plan and ensure staff were aware of and adhered to residents' assistance needs resulted in the resident's injury and constituted neglect as defined by facility policy.
Removal Plan
- CNA A in-serviced one-on-one by DON on resident positioning, bed mobility, using draw sheet, and getting assistance when needed.
- CNA A terminated and has not worked since.
- All staff in-serviced on Abuse/Neglect/Exploitation, Incidents/Accidents, and how to safely care for dependent residents, completed by ADON with Compliance Nurse oversight.
- DON/Administrator in-serviced on Abuse, Neglect, Incidents, and Investigating, including immediate suspension of employee accused of abuse/neglect, completed by Compliance Nurse.
- 100% audit completed to review plan of care, Kardex, and care profile on residents who are dependent assistance, completed by DON/ADON or designee with Compliance Nurse oversight.
- Care guides reviewed for compliance and accuracy, completed by DON/ADON or designee with Compliance Nurse oversight.
- Nursing staff in-serviced on guidance for accessing Kardex, care plans, and how to safely care for residents with positioning and incontinent care, completed by DON/ADON/designee.
- Weekend supervisor trained to monitor incidents/accidents on weekends and immediately report any issues identified to Administrator/DON by DON.
- All incidents reviewed and no other instances of abuse or neglect noted from the audit, completed by DON/Admin.
- Incident with Resident #1 self-reported via email by DON.
- Investigation initiated; facility self-reported the incident.
- All Abuse/Neglect allegations will be reported and investigated per policy; DON and Administrator will ensure investigations are completed timely.
- Administrator oversight provided by Regional President of Operations.
- No employees will be allowed to return to work until they have been in-serviced on the Abuse/Neglect policy and how to safely care for residents.
- Nurses will be responsible for ensuring compliance; DON/ADON/Admin will monitor.
- Incidents/Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor, and reported to Administrator immediately for investigation.
- Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents.
- Admin/DON will monitor to ensure compliance.