Failure to Provide Required Supervision and Two-Person Assist During Incontinent Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and did not use the required two-person assist while providing incontinent care to a resident with severe cognitive and physical impairments. The resident, who had diagnoses including dementia with agitation, heart disease, multiple fractures, muscle weakness, abnormal gait, contractures, and was dependent on staff for all activities of daily living (ADLs), required two-person assistance for transfers, bed mobility, and incontinent care as documented in her care plan and MDS. Despite these requirements, the CNA left the resident unattended on her side in bed to retrieve gloves, resulting in the resident falling from the bed. The incident was unwitnessed, but statements from staff and review of the resident's care plan confirmed that the resident was a high fall risk and required two-person assistance for all care activities. The CNA admitted to leaving the resident on her side and not having all supplies ready before starting care, contrary to her training and the resident's care plan. The resident was found on the floor with injuries including a rib fracture and contusions to her face and back. The resident was non-ambulatory, unable to self-propel, and had a history of falls and high fall risk scores since admission. Interviews with staff indicated that the requirement for two-person assistance, especially for residents on air mattresses or with mechanical lifts, was known or should have been known, and that leaving a dependent resident unattended during care was considered neglect. The facility's policies on fall prevention, abuse/neglect, and safe resident handling emphasized the need for proper supervision and adherence to care plans, which were not followed in this incident. The failure to provide adequate supervision and assistance directly led to the resident's fall and subsequent injuries.