Failure to Follow Two-Person Assist Care Plan Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan to prevent an accident for one resident at risk for falls. The resident had multiple diagnoses, including vascular dementia (moderate) without behavioral disturbance, end stage renal disease on dialysis, type 2 diabetes with diabetic polyneuropathy, depression, gout, and an acquired absence of the left foot. The resident’s MDS showed he was cognitively intact with a BIMS score of 15. Prior to the fall, his care plan and CNA care guide specified that he was dependent on staff for bed mobility, transfers, and locomotion, and required the assistance of two staff with a full-body Hoyer lift for transfers, as well as assist of two for ADLs and toileting per the mobility care plan. He was also care planned as being at risk for falls due to left-sided and generalized weakness. On the morning of the incident, a CNA who typically worked as a restorative aide was pulled to the hall to help get residents up and went in to assist this resident with morning cares. The CNA rolled the resident onto his left side and was performing toileting cares when the resident rolled off the bed, struck a chair next to the bed, and fell to the floor, landing face down. The CNA reported that she believed the resident was a one-person assist, although the care plan and CNA care guide required two-person assistance for ADLs and bed-related tasks. The CNA acknowledged that care guide sheets for each resident were posted inside the linen closet door on each hallway, that she knew this prior to helping the resident, and that she should have checked the sheet to verify whether another staff member was needed before providing care. Following the fall, nursing staff documented that the resident was found on the floor with facial cuts and was sent to the emergency department for evaluation. The ED record indicated that the resident reported falling out of bed while being assisted with dressing, hitting his head on the floor, and experiencing facial and right shoulder pain. Imaging revealed an equivocal minimally offset fracture of the distal right clavicle, and the ED impression documented a closed right clavicle fracture. The facility’s internal investigation concluded that the resident’s plan of care had not been followed, specifically that the CNA performed bed mobility alone when the resident required two staff for bed mobility, and that this failure to follow the care plan occurred at the time of the fall that resulted in the injury.
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