Failure to Provide Required Two-Person Assistance Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, stroke, and left hemiplegia, who was care planned as dependent on two staff for transfers and showers, was left unattended in a shower chair by a single CNA. The resident required a mechanical lift with two-person assistance for transfers, as documented in her care plan and MDS. Despite these requirements, the CNA attempted to manage the transfer alone and turned away to retrieve the mechanical lift, during which time the resident fell from the shower chair. The fall resulted in the resident sustaining acute fractures to the right great toe and first metatarsal, as confirmed by x-ray, and a laceration to the top lip. The resident experienced pain requiring PRN analgesics and a new order for tramadol, as well as a referral to orthopedics. The incident was witnessed, and the CNA involved acknowledged that she was alone with the resident, despite knowing the resident was a two-person assist, and attributed this to staffing shortages at the time. Interviews with staff confirmed that the facility's policy and the resident's care plan required two-person assistance for transfers and use of the mechanical lift. The CNA admitted to performing two-person assists alone on several occasions due to short staffing. There was no documentation of in-service training following the incident, and the fall was not reported as neglect, despite facility policy and regulatory definitions that classify such failures to provide necessary services as neglect.