Failure to Provide Required Two-Person Assistance During Bed Mobility and Transfers
Penalty
Summary
The facility failed to ensure that two residents who required assistance from two staff members for bed mobility and transfers were provided with the necessary supervision and support, resulting in accidents. In both cases, only one staff member provided care despite the residents' care plans and transfer status sheets clearly indicating the need for two-person assistance. This failure to follow the prescribed care plans led to both residents falling from their beds during care. One resident, who had anoxic brain damage and was in a persistent vegetative state, was completely dependent on staff for mobility and required two-person assistance for rolling side to side. During incontinence care, a CNA attempted to roll the resident alone, resulting in the resident falling from the bed and sustaining a laceration to the skull that required emergency room treatment and stitches. The CNA admitted to providing care alone because she was unable to find another staff member to assist, despite knowing the resident's care plan required two staff for such tasks. Another resident, also in a vegetative state with multiple medical conditions and dependent on staff for all activities of daily living, experienced a similar incident. While being cleaned, the resident was turned by a single CNA, contrary to the care plan that required two staff and the use of a mechanical lift for transfers. The resident fell from the bed, sustaining minor injuries including excoriations and a small hematoma. The CNA involved confirmed she did not wait for another staff member to assist, as required by the care plan.