Failure to Provide Required Assistance and Safe Equipment Use Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided care to a resident with significant medical needs, including cerebral infarction, left hemiplegia, and severe obesity, without the required assistance of a second staff member. The resident's care plan specified that two or more staff were needed for bed mobility and repositioning due to the resident's left-sided weakness and high body weight. Despite this, the CNA assisted the resident alone during a brief change, instructing the resident to turn to his left side, which led to the resident sliding off the bed and falling to the floor. At the time of the incident, the resident was using an air mattress that had been installed the previous day. The air mattress was not ordered by a physician, and there was no documentation in the resident's treatment or medication administration record to ensure that the mattress settings were appropriate for the resident's weight or that the mattress was being monitored for proper inflation. The CNA reported that the mattress was unstable and deflated on one side when the resident turned, contributing to the fall. The facility's protocol required verification of mattress settings and monitoring, but these steps were not followed for this resident. As a result of these failures, the resident fell from the bed and sustained an acute fracture of the right great toe. Interviews with staff confirmed that the air mattress was moved from another resident's bed without a physician's order and that the required two-person assistance for care was not provided at the time of the incident. The lack of adherence to established protocols for both staffing and equipment use directly led to the resident's injury.