Failure to Provide Required Two-Person Assist Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living and required a two-person assist for bed mobility and personal care, was left unsupervised by only one Certified Nursing Assistant (CNA) during repositioning and a brief change. The resident, who had significant medical conditions including type 2 diabetes, hypertension, dependence on a respirator, confusion, limited mobility, and contractures, was unable to assist in their own care. Despite the care plan and facility policy requiring two staff members for such assistance, the CNA proceeded alone, resulting in the resident sliding from the bed, striking their head, and sustaining a displaced intertrochanteric fracture of the left hip. Interviews with staff confirmed that the standard practice in the subacute unit was to use a two-person assist for residents with similar needs, and a buddy system was in place to ensure adequate supervision. The CNA involved admitted to providing care alone and not waiting for assistance, even though the resident was known to be a two-person assist. The Director of Nursing acknowledged that the CNA did not follow protocol, and the facility's policy emphasized the need for interventions based on residents' specific risks to prevent falls. The failure to provide adequate supervision and follow established protocols directly led to the resident's fall and injury.