Failure to Provide Required Supervision and Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a completely dependent resident, with diagnoses including dementia, muscle weakness, contractures, and hemiplegia, was not provided adequate supervision and assistance during incontinence care. The resident's care plan specified the need for two staff members to assist with rolling side to side and for transfers using a Hoyer lift, due to her inability to move or assist herself. However, the care plan did not clearly document the required number of staff for all activities of daily living, and there was no care plan addressing safety or bed mobility related to the use of a low air loss mattress. On the day of the incident, a CNA who was new to the facility provided incontinence care to the resident alone. The CNA was not shown where to find the resident's transfer and bed mobility information and had observed other aides providing care alone, leading her to believe that single-person assistance was sufficient. While turning the resident onto her side, the resident rolled out of bed and fell face down onto the floor, resulting in multiple rib fractures, a clavicle fracture, and a splenic laceration. The resident was completely dependent and unable to assist in her own care or maintain her position in bed. Interviews with facility staff confirmed that the resident required two-person assistance for rolling and transfers, and that this requirement was not communicated or implemented during the incident. The facility's failure to ensure that the resident's care plan for two-person assistance was followed during incontinence care directly led to the resident's fall and subsequent injuries.