Failure to Provide Required Two-Person Assistance During Repositioning Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during peri care and repositioning of a resident who was totally dependent on staff for all activities of daily living. The resident, who was nonverbal, in a vegetative state, and required two-person assistance for all repositioning and peri care as documented in his care plan and Kardex, was repositioned by a single CNA without the required help. During this process, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The resident had a complex medical history, including long-standing alcohol use disorder, alcoholic encephalopathy, cirrhosis, pancreatitis, gastrointestinal bleeding, hypertension, and an anoxic brain injury requiring a tracheostomy and gastrostomy. He was admitted for skilled nursing care, medical management, and total assistance with activities of daily living. The care plan clearly indicated the need for two-person assistance for all repositioning and peri care due to his severely impaired cognition and physical limitations. Despite being aware of the care plan requirements and having received prior training, the CNA proceeded to reposition the resident alone, did not request assistance, and did not follow established protocols. Multiple staff interviews confirmed that the CNA knew the resident required two-person assistance and that the care plan and Kardex were accessible and should have been followed. The incident was attributed directly to the CNA's failure to adhere to the resident's care plan, resulting in significant injury to the resident.