Failure to Provide Required Staff Assistance During Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate staff assistance and implement fall prevention interventions during care for a resident with a history of repeated falls, dementia, impaired mobility, and incontinence. The resident was assessed as requiring substantial/maximal assistance for bed mobility and was care planned to need two staff members for bed mobility and toileting. Despite these documented needs, a CNA provided incontinence care alone, during which the resident rolled off the bed and sustained a skin tear. The CNA stated she believed the resident could roll independently and was unaware of the requirement for two-person assistance, which was confirmed as necessary by the LPN Unit Manager and the Director of Nursing. Observations further revealed that, on another occasion, a CNA again provided incontinence care to the resident alone, despite the care plan specifying two-person assistance. The facility's policies defined substantial/maximal assistance as requiring more than half the effort from the helper, including lifting or holding the trunk or limbs. The failure to follow the care plan and provide the required level of assistance directly led to the resident's fall and injury.