Failure to Provide Required Two-Person Assist During Bed Bath Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bathing and required the assistance of two staff members according to her care plan, was provided a bed bath by only one certified nurse aide (CNA). The resident's care plan and Minimum Data Set (MDS) assessments indicated that her abilities fluctuated and that she was a high fall risk, necessitating two-person assistance for bathing and bed mobility. Despite these documented needs, the resident was rolled onto her side by a single CNA during a bed bath, which resulted in her sliding off the bed and falling to the floor. The incident led to the resident sustaining a left hip fracture, as confirmed by hospital documentation and x-ray, which required surgical intervention. The resident reported that her legs went over the side of the bed while powder was being applied to her back, causing her to fall. Staff interviews and witness statements corroborated that only one CNA was present at the time of the incident, and the resident was turned away from the caregiver, which was not in accordance with proper nursing care or the resident's care plan requirements. The facility's investigation and staff interviews confirmed that the care plan specified the need for two caregivers during bathing and repositioning, and that this protocol was not followed at the time of the incident. The failure to provide the appropriate level of care and assistance as outlined in the resident's care plan directly resulted in an avoidable fall and actual harm to the resident.