Failure to Provide Required Two-Person Assistance During Incontinence Care Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required the assistance of two staff members for incontinence care and bed mobility due to physical weakness, right hemiparesis, morbid obesity, and a history of cerebrovascular accident, was provided care by only one Certified Nursing Assistant (CNA). The resident's care plan and Kardex clearly indicated the need for two-person assistance for all activities of daily living, including incontinence care and bed mobility. During morning care, the CNA assisted the resident alone, instructing the resident to grab the bed bar and turning away to retrieve cream. At this moment, the resident rolled out of bed, fell to the floor, and sustained a proximal humerus fracture of the right arm. The resident was alert, verbal, and complained of pain, and was subsequently transferred to the hospital for further evaluation and treatment. The CNA acknowledged awareness of the two-person assist requirement but stated that another staff member was not available at the time. The Director of Nursing confirmed that staff are expected to follow the care plan and minimum staffing requirements as outlined in the facility's policies. The facility's fall prevention policy required individualized interventions based on assessed risk, but this was not followed in the resident's case, directly resulting in the fall and injury.