Failure to Provide Required Two-Person Assistance Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for bed mobility and incontinent care was left unsupervised by only one CNA during care. The resident, an elderly female with multiple diagnoses including morbid obesity, muscle weakness, dementia, and a history of cerebral infarction, was documented in her care plan, Kardex, and MDS assessments as needing two staff members for bed mobility and transfers. Despite these documented requirements, the CNA proceeded to provide care alone, resulting in the resident sliding off the bed and sustaining a significant injury. The incident took place when the CNA attempted to change the resident's brief without waiting for a second staff member, as required by the resident's care plan and facility protocols. The resident slid off the bed, landing on her feet, but her knees buckled due to her inability to bear weight, and she was guided to the floor. Following the fall, the resident complained of pain in her right knee, and subsequent assessment and x-ray revealed an acute fracture of the right distal femur, necessitating hospitalization and surgical intervention. Interviews and record reviews confirmed that the CNA was aware of the two-person assist requirement but cited staffing shortages as the reason for acting alone. Other staff members and nursing leadership confirmed that the resident's care plan and Kardex clearly indicated the need for two-person assistance for bed mobility and transfers. The failure to follow established protocols and provide adequate supervision directly led to the resident's fall and injury.