Failure to Provide Adequate Staff Assistance During In-Bed Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including hemiplegia, hemiparesis, severe contractures, and total care needs, was not provided with adequate staff assistance during perineal care in bed. The facility's policy required that supervision and assistance be based on individual resident needs and identified hazards, but on the day of the incident, only one CNA was present to assist the resident, despite multiple staff interviews indicating that two-person assistance was necessary due to the resident's severe contractures and inability to help with care. During the incident, the CNA rolled the resident to one side to perform care and then moved to the other side of the bed. While the CNA was walking around the bed, the resident shifted and rolled off the bed, resulting in a fall. The resident sustained a left femoral neck fracture and a left frontal scalp hematoma, requiring emergency medical evaluation. The CNA reported that she was trained to provide one-person assistance for this resident, but other staff members stated that two-person assistance was typically required and that the CNA had been trained accordingly. Interviews with other CNAs and nursing staff confirmed that the resident's care needs required two people to safely provide assistance and maintain posture during bed mobility. The Director of Nursing and the Administrator were unable to explain why the CNA did not have a second person assisting and acknowledged that additional help could have been provided. The facility failed to ensure that adequate supervision and assistance were provided according to the resident's assessed needs, resulting in actual harm.