Failure to Provide Required Two-Person Assistance During Toileting Results in Resident Fall and Major Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, dementia with agitation and anxiety, reduced mobility, and joint stiffness was not provided adequate toileting assistance as required by their care plan. The care plan specifically stated that two caregivers must remain with the resident for the entire toileting process due to a history of falls. On the day of the incident, the resident was assisted to the toilet by two CNAs using an EZ Stand. However, after the resident soiled their clothing, one CNA exited the room, leaving the other CNA to continue assisting the resident alone during a clothing change. While the remaining CNA was changing the resident's soiled clothing, the resident leaned to the right, lost balance, and fell, resulting in significant injuries including multiple facial fractures and a subdural hematoma. The incident report and investigation confirmed that the care plan was not followed, as only one staff member was present during a critical part of the toileting process, directly leading to the resident's fall and injuries.