Failure to Provide Required Two-Person Assistance During Incontinent Care Results in Resident Fall and Fatal Injuries
Penalty
Summary
A deficiency occurred when a resident, who was assessed as totally dependent on staff for toileting hygiene and for turning and repositioning in bed, was not provided the required two-person assistance during incontinent care. The resident's Minimum Data Set (MDS) indicated that he was unable to assist in turning himself and required two staff members for safe repositioning. Despite this, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without the help of another staff member, contrary to the resident's care plan and facility policy. During the incident, the CNA raised the resident's bed to her waist level and attempted to pull the resident towards her using a draw sheet. As she did so, the resident slid out of bed and landed face down on a floor mat. The CNA called for help, and a Licensed Vocational Nurse (LVN) responded, finding the resident unresponsive. The resident was subsequently transferred to a general acute care hospital, where he was diagnosed with multiple traumatic injuries to his neck and spine, including ligamentous injuries, spinal cord compression, hemorrhage, and suspected fractures. The resident's medical history included a left humerus fracture, congestive heart failure, generalized muscle weakness, and myasthenia gravis. Following the fall, the resident required intubation and mechanical ventilation, and after consultation with neurosurgery and the family, comfort care was initiated. The resident passed away as a result of sequelae from blunt traumatic injuries sustained in the fall. Interviews with facility staff confirmed that the CNA was not aware of the two-person assistance requirement, and the facility's policy required the appropriate number of staff for safe turning and repositioning.