Failure to Follow Two-Person Assist Protocol Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required two-person assistance for bed mobility and incontinent care. The CNA performed incontinent care and repositioning alone, despite the resident's care plan and Kardex clearly indicating the need for two staff members due to the resident's severe cognitive impairment, hemiplegia, and functional limitations in all extremities. The CNA did not seek assistance, stating that other staff were busy, and attempted to complete the task alone. During the process of changing the resident and repositioning her in bed, the CNA rolled the resident too close to the edge of the elevated bed, resulting in the resident falling to the floor. The resident was found face down, unable to use her arms to break the fall, and sustained significant injuries including a left hip fracture, lacerations above the left eye, and a hematoma on the forehead. The resident was assessed by nursing staff and subsequently sent to the emergency room for further evaluation and treatment. Interviews with facility staff confirmed that the CNA was aware of the resident's need for two-person assistance and had received prior in-service training on using the Kardex to determine required assistance levels. Documentation and staff statements indicated that the CNA knowingly disregarded established protocols and the resident's care plan, directly leading to the resident's fall and injuries. The incident was identified as a failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents.