Failure to Provide Required Two-Person Assist Leads to Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was care planned as requiring a two-person assist for bed mobility and incontinence care, sustained a fall during incontinence care that was being provided by only one CNA. The resident had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, vascular dementia, and a history of right shoulder injuries and a left humerus fracture. Despite the care plan and Kardex indicating the need for two-person assistance, the CNA provided care alone, stating she was unaware of the requirement and had previously performed the task solo. During the incident, the resident attempted to assist with repositioning, resulting in a fall from the bed and subsequent injuries, including pain and skin tears. Interviews with multiple CNAs and nursing staff confirmed that the resident was dependent on two-person assistance for most ADLs, including bed mobility and toileting, due to left-sided paralysis and insufficient upper body strength. The CNA involved in the incident reported that she was not aware of the two-person assist requirement documented in the Kardex and care plan. Other staff members corroborated that the resident had always required substantial assistance and that this information was available in the Kardex and communicated during shift reports. Documentation and interviews revealed that the care plan had consistently indicated the need for two-person assistance since its initiation. However, there was a lack of adherence to this requirement at the time of the fall, as only one CNA was present during the provision of care. The Director of Nursing acknowledged that staff should have followed the care plan instructions regarding the number of staff required for assistance, and that the resident's environment was not maintained as free from accident hazards as possible due to this lapse.