Failure to Provide Required Two-Person Assist During Incontinence Care Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and safety during incontinence care for a resident who was completely dependent on staff for bed mobility and required a two-person assist, as documented in her care plan and Kardex. On the morning of the incident, only one CNA was present to provide incontinence care, despite the resident's need for two staff members for safe bed mobility. During the care, the CNA pulled the draw sheet while the resident attempted to hold onto the grab bar, resulting in the resident losing her grip and falling out of bed onto her knees. The resident, who was cognitively intact but at risk for falls due to muscle weakness and recent hospitalization, reported significant pain following the fall. Initial assessment noted knee pain without visible injury, but subsequent evaluation and imaging revealed a fracture of the distal femur. Staff interviews confirmed awareness of the two-person assist requirement, and the CNA involved acknowledged that the absence of a second staff member contributed to the fall. The facility's fall prevention policy did not address the specific circumstances of this incident.