Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for bed mobility, was not provided care according to their established plan. The resident's care plan and facility policy required two staff members to assist with bed mobility due to the resident's physical limitations, including hemiplegia and a history of falls. Despite this, a nurse aide provided incontinence care alone, rolling the resident onto their side without assistance. During the care episode, the nurse aide turned away to retrieve a clean brief while maintaining only one hand on the resident. The resident continued to roll toward the edge of the bed, and the aide was unable to prevent the resident from falling. The resident fell from the bed, striking their head on an oxygen concentrator and sustaining a laceration, multiple subdural hematomas, and a closed nasal fracture. The incident was witnessed by another staff member who responded to the aide's call for help and found the resident on the floor with facial bleeding. Facility documentation and staff interviews confirmed that the nurse aide was aware of the requirement for two-person assistance but failed to follow the resident's care plan. The facility's internal investigation substantiated neglect due to the failure to provide care as planned, resulting in actual physical harm to the resident. The resident required hospital evaluation and treatment for the injuries sustained during the incident.