Failure to Follow Care Plan for High-Risk Resident During Ambulation and Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow an existing care plan for a resident with significant functional limitations and identified fall risk. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma, and had intact cognition per an MDS assessment. The MDS and therapy assessments documented lower extremity impairment, a need for substantial/maximal assistance for bed mobility and sit-to-stand, dependence for toilet transfers and walking, and poor strength and balance. Therapy-to-nursing communication and the Kardex specified that the resident required substantial/maximal assistance, use of a sit-to-stand lift for transfers, wheelchair for ambulation, and that ambulation with a rolling walker was to occur in therapy only due to the level of assistance and safety cues required. Despite these documented needs and care plan interventions, on the morning of 11/15/2025 a CNA responded to the resident’s call light and assisted the resident out of bed using only a walker and grippy socks, without a gait belt or other assistive devices, and without checking the Kardex. The CNA attempted to walk the resident to the bathroom with standby assist, turned away to open the bathroom door, and then heard a loud sound. When she turned back, the resident was found on the floor on his back and initially unresponsive. The incident report and subsequent interviews confirmed that the resident had been ambulated by nursing staff, contrary to the care plan that required two-person substantial/maximal assistance with a sit-to-stand lift for transfers and specified that ambulation with a rolling walker was to occur in therapy only. Following the fall, the resident was noted to have a high PAINAD score with signs of pain, lethargy, and injuries including a skull fracture and subdural hematoma with brain compression. The death certificate later documented the immediate cause of death as complications of blunt force head trauma from a fall, with the place of injury identified as the nursing home. Interviews with the CNA, an LPN, and the DON confirmed that staff were expected to use the care plan or Kardex to determine required assistance levels, that the care plan was not followed at the time of the incident, and that the resident had previously ambulated with nursing staff despite the documented restrictions and identified fall risk.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.