Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, right-sided hemiplegia and hemiparesis, and severe cognitive impairment was not provided with the required level of assistance for bed mobility as outlined in their comprehensive care plan. The care plan and Kardex specified that the resident was dependent on two or more staff members for bed mobility, including rolling in bed and toileting hygiene, due to their high risk for falls and inability to carry out activities of daily living independently. On the day of the incident, a certified nurse aide (CNA) provided incontinence care to the resident without the assistance of a second staff member, despite being aware of the care plan requirements. During the care, the resident rolled out of bed and sustained a multilayered facial laceration and swelling to the left eye. The CNA attempted to prevent the fall but was unable to do so alone. The resident was subsequently transferred to the hospital, where they required surgical repair of the facial laceration and additional medical evaluation. Interviews with facility staff, including the CNA involved, the former Registered Nurse Manager, and administrative personnel, confirmed that the care plan was not followed at the time of the incident. The staff acknowledged that the resident required a two-person assist for bed mobility and that failure to adhere to this protocol resulted in the resident's fall and injury. The incident was recognized as causing actual harm to the resident, though it was not classified as Immediate Jeopardy.