Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided shower assistance to a resident who was care planned for two-person assistance with activities of daily living (ADLs), including bathing and transfers. The resident had a history of Alzheimer's disease, dementia, moderate intellectual disabilities, and was identified as high risk for falls. The care plan specifically required care in pairs due to the resident's cognitive impairment, fall risk, and behavioral concerns, including threatening harm to staff. Despite these documented interventions, the CNA assisted the resident alone in the shower. During the shower, the resident attempted to stand from the shower chair without adequate support, resulting in a fall. The resident sustained a laceration above the right eye requiring four sutures, an abrasion to the right knee, and was transferred to the emergency room for evaluation. Initial assessments and imaging did not reveal a hip fracture, but the resident subsequently experienced a decline in mobility, increased pain, and difficulty ambulating. Over the following days, the resident's right leg became painful, discolored, and showed signs of injury, eventually leading to the diagnosis of a right femoral neck fracture eight days after the fall. Interviews and documentation confirmed that the CNA was aware of the care plan requirement for two-person assistance but proceeded alone. The Director of Nursing and the attending physician both indicated that the hip fracture was likely caused by the fall during the unsupervised shower. The facility's failure to follow the care plan and provide adequate supervision and assistance directly resulted in the resident's injuries and subsequent decline in function.