Failure to Provide Required Two-Person Assist Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist for all activities of daily living (ADL) care and transfers was provided incontinent care by only one Certified Nursing Assistant (CNA). During this care, the resident rolled out of bed and fell to the floor, resulting in a distal fracture of the left femur and a fracture of the lower end of the right tibia. The resident's care plan and Minimum Data Set (MDS) assessment clearly indicated the need for two-person assistance due to significant physical and cognitive impairments, including hemiplegia, contractures, seizures, altered mental status, and a history of attempting to get out of bed unassisted. The facility's policy on incidents and accidents required staff to provide immediate assistance and follow established protocols to prevent accidents. However, interviews and record reviews revealed that the CNA entered the resident's room alone to provide care, contrary to the care plan and facility policy. The CNA left the resident on his side to retrieve an item from the hallway, during which time the resident continued to roll and fell from the bed. Documentation in the electronic medical record and staff interviews confirmed that the resident was dependent on staff for all ADLs and required two-person assistance for bed mobility and transfers. Further interviews with facility staff, including the Administrator, LPNs, and other CNAs, confirmed that the resident's need for two-person assistance was documented in the care plan, Kardex, and Point Click Care (PCC) system. Staff were expected to communicate changes in resident care needs during shift changes and to verify assistance requirements in the PCC system. Despite these protocols, the failure to provide adequate supervision and follow the resident's care plan directly led to the resident's fall and subsequent injuries.