Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for a resident who required extensive assistance with bed mobility and toileting. According to the care plan and occupational therapy notes, the resident was dependent on two staff members for these activities. However, on the day of the incident, only one nurse aide was present while removing the resident from a bedpan. During this process, the resident shifted her weight, slipped through the aide's arms, and fell to the floor between the beds. Documentation and staff interviews confirmed that the resident was supposed to have two staff assisting during such transfers, but this protocol was not followed at the time of the fall. As a result of the fall, the resident sustained injuries including bleeding and bruising to the face, skin tears, and a nondisplaced fracture of the third digit of the right hand. The incident was corroborated by nurse aide documentation, witness statements, and a fall investigation form, all indicating that only one staff member was present during the transfer. Interviews with the Director of Therapy and the Director of Nursing further confirmed that the resident required two-person assistance for bed mobility and toileting, and that this standard was not met during the incident.