Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for bed mobility was provided care by only one certified nurse aide (CNA). The resident, who had diagnoses including dementia, Alzheimer's disease, and a history of cerebral infarction and ventriculoperitoneal shunt, was assessed as having moderate cognitive impairment and was totally dependent on staff for bed mobility and transfers. The care plan and CNA care guide both specified the need for two-person physical assistance for this resident. On the day of the incident, the CNA was preparing to change the resident's draw sheet and left the resident positioned on their left side while retrieving a clean sheet from the end of the bed. During this time, the resident rolled off the bed and fell to the floor. The CNA was aware of the two-person assist requirement but did not seek assistance from another staff member. The fall was witnessed by the CNA, and subsequent assessment revealed the resident sustained fractures to the L1 and L2 lumbar vertebrae and a laceration to the posterior scalp, requiring hospital admission and sutures. Interviews with facility staff confirmed that the CNA did not follow the care plan instructions and did not request help from another aide, despite knowing the resident's needs. Other staff members, including a nurse and a supervisor, indicated that the incident could have been prevented if the care plan had been followed. The resident's condition at the time of the incident included significant physical and cognitive impairments, making them highly dependent on staff for safe mobility.