Failure to Provide Required Two-Person Assist Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide the required two-person assistance during incontinent care for a resident with a history of cerebral infarction, morbid obesity, and moderate cognitive impairment. The resident's care plan and Minimum Data Set (MDS) both indicated a need for two-person assistance for toileting and hygiene. Despite this, the CNA performed the care alone, stating she did not want to wait for another staff member because it was lunchtime. During the process of providing care, the CNA turned the resident to her right side, resulting in the resident slipping off the bed and falling to the floor. The CNA called for help, and another CNA arrived, followed by a registered nurse (RN) who assessed the resident. The resident complained of right shoulder pain and was unable to move her right arm due to pain. X-rays confirmed an acute displaced fracture of the right distal humerus. Interviews with staff confirmed that the resident was dependent on two-person assistance for all activities of daily living both before and after the incident. The CNA involved admitted to having previously performed care for the resident alone, despite knowing the care plan requirements. The incident was reported to facility leadership, and the event was documented as past non-compliance, with the facility having corrected the issue prior to the survey.