Failure to Follow Two-Person Assist Protocol Resulting in Resident Fall
Penalty
Summary
The facility failed to protect a resident from neglect when a nurse aide provided care without following the required two-person assist protocol for a resident with significant mobility impairments. The resident, who had diagnoses of muscle wasting, muscle weakness, and abnormal gait, was care planned and had physician orders for a full body mechanical lift and two-person assistance for all transfers, hygiene, and bed repositioning. Despite these documented requirements, the nurse aide attempted to provide care alone, resulting in the resident rolling out of bed and sustaining a head laceration. The incident was reported by the nurse aide, who admitted to not seeking help as typically required, and was corroborated by the resident's statement and facility documentation. Facility policies reviewed emphasized the necessity of using appropriate transfer techniques and ensuring two-person assistance for residents with such needs. Staff interviews confirmed that aides are expected to reference the Kardex and report sheets for transfer status and to wait for assistance when required. The incident was acknowledged by facility leadership as a failure to protect the resident from neglect, as the established protocols and care plan directives were not followed, directly leading to the resident's fall and injury.