Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as requiring the assistance of two staff members for bed mobility and ADL care, did not receive the required level of supervision and assistance. The resident had a medical history including hemiplegia/hemiparesis due to cerebral infarction, pain, peripheral vascular disease, and hypertension. According to the records, the resident was dependent for toileting hygiene and required substantial to maximum assistance for rolling in bed. During an episode of incontinence care, only one CNA was present, despite the care plan indicating a two-person assist was necessary. The CNA providing care was unable to find another staff member to assist and proceeded to provide care alone. During the process, the resident had a large bowel movement, prompting the CNA to leave the resident unattended on her side to retrieve additional supplies from a cart located at the doorway. While unattended, the resident attempted to reach for an item on her bedside table and subsequently rolled off the bed. The resident was found on the floor, and although initial assessments did not reveal injuries, she later exhibited altered mental status and was sent to the hospital, where imaging revealed a fracture of the left femur near the knee. Interviews and record reviews confirmed that the CNA was aware of the two-person assist requirement but did not adhere to it due to the unavailability of additional staff at the time. The incident was not initially recognized as a fall by facility leadership, and the injury was only identified after the resident was transferred to the hospital. The failure to provide adequate supervision and assistance as outlined in the resident's care plan directly led to the resident sustaining a significant injury.