Failure to Maintain Two-Person Assistance During High-Risk Resident Care Resulting in Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that two staff members remained at the bedside during incontinence care for a resident who was identified as high risk for falls and required two-person assistance for turning and repositioning. The resident, who had diagnoses including end stage renal disease, weakness, and difficulty walking, had a documented fall risk score of 10, indicating high risk according to the facility's fall prevention policy. During an episode of ADL care, one staff member (the DON) stepped away from the bedside to retrieve a garbage can while the other staff member (a CNA) continued with care. This resulted in the resident sliding out of bed and falling to the floor. The incident report and staff interviews confirmed that the resident required substantial or maximal assistance for hygiene and repositioning, with care plans specifying two-person assistance at all times. Despite this, the staff did not ensure all necessary items were at the bedside before starting care, leading to one staff member leaving the resident unattended. The fall resulted in the resident sustaining a scalp hematoma and requiring transfer to a hospital for evaluation and treatment.