Failure to Provide Required Two-Person Assistance During Care Resulting in Resident Fall
Penalty
Summary
A resident with a history of nontraumatic intracerebral hemorrhage, traumatic compartment syndrome, paraplegia, and dysphagia was admitted to the facility and assessed as having impaired cognition with a BIMS score of six. The resident's care plan and comprehensive evaluation indicated a requirement for two-person assistance during self-care and mobility, specifically for toileting and hygiene care, due to the risk of falls and impaired ADL performance. Interventions included placing the bed against the wall and ensuring two staff members were present during care. On the date of the incident, the resident was receiving perineal care from a single CNA, despite the documented need for two-person assistance. While being turned to the left side, the resident slid off the bed, struck his head on a nearby chair, and landed on his back. The resident was alert and responsive but reported right-sided neck pain. The DON confirmed that only one staff member was present during the incident, which was not in accordance with the resident's care plan and facility expectations.