Failure to Provide Adequate Staff Assistance During Therapy Session Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but required maximum assistance with mobility and transfers due to overweight status and functional decline, was left without adequate staff support during a therapy session. The resident's care plan specified that two staff members were needed to assist during therapy sessions. Despite this, a physical therapist assistant (PTA) proceeded with the session alone, attempting to have the resident sit on the side of the bed and then stand, even though the resident was dependent for bed mobility and did not stand independently. During the session, the PTA let go of the resident and walked to the other side of the bed to reposition the resident, leaving the resident unsupported. The resident subsequently fell forward off the bed, hitting the bedside table and sustaining a head laceration that required emergency treatment and 15 staples. Witnesses, including another resident and staff, confirmed that the PTA did not attempt to assist or prevent the fall and that the resident typically required two staff members for all transfers and mobility tasks. Interviews with staff, including a CNA, LPN, DON, and the resident's nurse practitioner, consistently indicated that the resident was dependent on staff for mobility and that the PTA should have waited for additional assistance before proceeding. The facility's safety policy also required two or more persons to assist when necessary for resident safety. The failure to follow the care plan and facility policy directly resulted in the resident's fall and injury.