Failure to Provide Required Two-Person Assistance During Resident Care Results in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and personal hygiene and required the assistance of two staff members during care, was provided care by only one nursing assistant. The resident had significant medical conditions, including anoxic brain damage, seizures, and diabetes, and was documented in both the Minimum Data Set (MDS) and care card as needing two staff for bed mobility and hygiene tasks. Despite these documented requirements, the nursing assistant performed a full bed bath and attempted to change the resident alone, during which the resident rolled out of bed and sustained injuries, including a facial laceration and abrasions, necessitating immediate transfer to the hospital. Interviews with staff revealed that the nursing assistant was unaware of the documented requirement for two-person assistance and typically worked alone with the resident. The Director of Nursing Services also did not acknowledge the two-person requirement, despite its presence in the resident's care documentation. As a result of the failure to follow the care plan and MDS directives, the resident experienced a fall with multiple injuries and required hospitalization.