Failure to Provide Required Two-Person Assistance Resulting in Resident Fall
Penalty
Summary
A resident with diagnoses including dementia, chronic obstructive pulmonary disease, heart failure, diabetes, and bilateral above-knee amputation was identified as cognitively impaired and required extensive assistance of two staff for bed mobility. Despite this, the resident was provided care by only one CNA, who attempted to change the resident alone. During the care, the resident became agitated and combative, let go of the grab bar, and fell to the floor. The resident sustained an injury with active bleeding above the right amputation site, necessitating transfer to the hospital for further evaluation. The resident's care plan specifically required two-person assistance for bed mobility due to impaired mobility and cognitive status. Documentation and interviews confirmed that the CNA was aware of the resident's combative behavior and the need for two-person assistance but proceeded alone. The DON acknowledged that only one CNA was present during the incident, contrary to the care plan and facility fall management guidelines, which required individualized fall prevention interventions based on assessment.