Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with advanced end-stage liver disease and ascites, who required extensive assistance from two staff members for positioning onto a bedpan, was assisted by only one CNA. The resident's care plan specifically documented the need for a two-person assist due to limited mobility and the need for support related to an enlarged abdomen. On the day of the incident, two family members and two EMTs were waiting outside the resident's room while the CNA provided care alone. During this time, the resident was heard yelling about an impending fall, followed by a loud thump. The resident was subsequently found on the floor, approximately ten feet from the bed, having knocked over flowers and a lamp. Clinical records and interviews confirmed that the CNA did not follow the care plan, which required two-person assistance for bedpan use. The resident sustained a left clavicle fracture and reported pain in the left upper extremity as a result of the fall. The incident was corroborated by EMS and hospital records, as well as interviews with facility staff, who acknowledged that the care plan was not followed at the time of the event.