Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in harm. The resident in question required extensive assistance from two staff members for bed mobility and toileting, as documented in the care plan and occupational therapy notes. Despite this, a nurse aide provided incontinent care and attempted to remove the resident from a bedpan alone, without the required second staff member. During this process, the resident shifted her weight, slipped through the aide's arms, and fell to the floor between the beds. The incident resulted in bleeding, bruising, skin tears, and a nondisplaced fracture of the third digit of the right hand, as confirmed by emergency room evaluation and X-ray. Interviews with facility staff, including the Director of Therapy and the Director of Nursing, confirmed that the resident was to be assisted by two staff members during bed mobility and toileting hygiene, specifically when removing her from the bedpan. The nurse aide involved acknowledged performing care alone and cited time constraints and the resident's urgency as reasons for not waiting for a second staff member. Documentation and witness statements corroborated that only one staff member was present at the time of the fall, in direct violation of the resident's care plan and facility policy.