Failure to Provide Required Two-Person Assistance During ADLs Resulted in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including osteoarthritis, osteoporosis, morbid obesity, generalized muscle weakness, and lack of coordination, was not provided adequate supervision during activities of daily living (ADLs). The resident was assessed as being dependent on staff for all ADLs and required the assistance of two or more staff members for tasks such as turning, repositioning, and personal care. Despite this documented need, a certified nursing assistant (CNA) provided care alone, during which the resident slid off the bed while being turned for a diaper change. The CNA was unable to prevent the fall due to the resident's weight and called for assistance after the incident occurred. Interviews with staff, including the CNA involved, a licensed vocational nurse (LVN), and the assistant director of nursing (ADON), confirmed that the resident should have received two-person assistance for all ADLs to ensure safety and prevent falls. Documentation and care plans also indicated the requirement for two-person assistance. The facility's policy on ADL support emphasized providing appropriate care and assistance for residents unable to perform ADLs independently. The failure to follow these protocols resulted in the resident falling from the bed and being sent to the emergency room, although no fractures were found.