Failure to Provide Required Two-Person Assistance During Incontinence Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was care planned and documented as requiring two-person assistance for bed mobility and incontinence care, was provided care by a single nurse aide. The resident had significant medical conditions, including osteomyelitis of the lumbar vertebra, type 2 diabetes mellitus, and an infection of the heart valve, and was also on anticoagulant therapy. The care guide, therapy assessments, and the resident's care plan all indicated the need for maximal assistance with bed mobility and transfers due to impaired mobility, cognitive impairment, and incontinence. During incontinence care, the nurse aide rolled the resident onto her side without assistance, contrary to the care guide instructions. The aide was positioned on the left side of the bed and rolled the resident away from herself, resulting in the resident rolling off the bed and onto the floor. The bed was raised to just below hip height at the time. The resident complained of pain in her right hip and shoulder and reported hitting her head on the nightstand during the fall. Staff interviews confirmed that the aide was aware of the care guide location but chose to perform the care alone, believing she could manage without assistance. Following the fall, the resident was assessed by nursing staff and the nurse practitioner, who noted pain, external rotation, and shortening of the right leg, raising suspicion of a hip fracture. The resident was transferred to the emergency room, where imaging confirmed a complex right hip fracture with subluxation and impaction, as well as additional injuries. The resident required hospitalization and subsequent hip replacement surgery. Interviews with staff and review of documentation confirmed that the facility's protocol for two-person assistance was not followed during the incident.