Failure to Provide Required Two-Person Assistance During Care Results in Resident Fall and Harm
Penalty
Summary
A deficiency occurred when a resident with paraplegia and significant impairment in both upper and lower extremities, who was dependent on staff for all activities of daily living including bed mobility, was not provided with the required two-person assistance during care. The resident's care plan did not reflect the need for two-person assistance with bed mobility, despite this requirement being documented in multiple MDS assessments and confirmed by several staff members. During a sheet change, a single unlicensed staff member attempted to turn the resident, resulting in the mattress lifting and the resident falling to the floor. The fall resulted in the resident sustaining an acute subarachnoid hemorrhage, requiring hospitalization and ICU admission. Interviews with the resident and multiple staff confirmed that the resident was unable to roll independently and typically required two staff for bed mobility. The incident was attributed to inadequate supervision and failure to follow the documented care needs, as only one staff member was present during the incident, contrary to the resident's assessed requirements.