Failure to Provide Required Two-Person Assistance Resulting in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) provided incontinent care to a resident who required two-person assistance for all activities, including toileting and bed mobility, without the required help. The CNA was aware of the resident's care plan and dependency level but chose to proceed alone due to time constraints during lunch. While turning the resident to her right side, the resident slipped off the bed and fell to the floor. The resident, a female with a history of cerebral infarction, morbid obesity, and moderate cognitive impairment, was always incontinent and dependent on two staff for toileting hygiene, as documented in her care plan and Minimum Data Set (MDS). Following the fall, the resident complained of right shoulder pain and was unable to move her right arm. Assessment and x-rays revealed an acute displaced fracture of the right distal humerus. Interviews with staff confirmed that the CNA had previously provided care to the resident alone, despite knowing the two-person assist requirement. Other staff, including another CNA and a registered nurse (RN), responded after the incident, assessed the resident, and facilitated further medical evaluation. The facility's policy required residents to be free from abuse and neglect, including adherence to care plans specifying assistance levels.