Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as being totally dependent on staff for activities of daily living (ADL) care and bed mobility, experienced a fall resulting in harm. The resident's care plan and Kardex indicated a need for two-person assistance for toileting hygiene and for being rolled from left to right. Despite these documented requirements, a single GNA provided ADL care and attempted to turn the resident alone, during which the resident slid off the bed and fell to the floor. The incident was witnessed by the GNA, who had raised the bed to waist height and asked the resident to use the upper bed rails to assist with turning. The resident continued to roll toward the left side, with their legs sliding off the bed, and the GNA was unable to prevent the fall due to the resident's size. The GNA called for help, and the RN Unit Manager responded to assess the resident, who complained of pain in both legs. The resident was subsequently transferred to the hospital, where a fracture to the left leg was diagnosed. Interviews with facility staff, including the DON, RN Unit Manager, and MDS Coordinator, confirmed that the resident was known to require two-person assistance for turning and hygiene. The GNA involved in the incident acknowledged being re-educated on proper procedures following the event. The facility's failure to provide the required level of supervision and assistance directly led to the resident's fall and injury.