Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, limited range of motion, and classified as a two-person assist for bed mobility was not provided the required level of assistance during care. Despite the resident's explicit warning to the aide that they were a fall risk and required two staff for turning, only one aide proceeded to turn the resident in bed. This resulted in the resident falling from the bed, hitting their head, and experiencing significant pain and trauma. The resident was subsequently sent to the hospital for evaluation and treatment. The resident's care plan and Kardex indicated a need for two-person assistance for bed mobility, but this was not followed at the time of the incident. The aide involved was newly hired and, according to facility records, had received bed mobility training during orientation. However, the aide did not use proper positioning techniques and rolled the resident away from themselves, leading to the fall. The incident report and facility investigation confirmed that improper positioning and failure to follow the two-person assist requirement directly contributed to the resident's fall and injury. Following the fall, the resident experienced increased pain, anxiety, and a decline in participation in daily activities. The resident reported ongoing pain, fear of being moved, and a reluctance to engage with staff. Medical records documented increased requests for pain medication and new orders for scheduled pain management. The facility's review of the incident identified that the Kardex allowed aides to choose the level of assistance, which should have been specified by therapy, contributing to the confusion and subsequent failure to provide adequate supervision and assistance.