Failure to Provide Required Two-Person Assistance During Resident Care
Penalty
Summary
The facility failed to ensure that two-person assistance was provided during care for a resident who was care planned as requiring such assistance for all activities of daily living (ADLs) due to total dependence and inability to assist with turning or repositioning. Despite the care plan and staff knowledge that the resident was dependent and unable to turn or hold herself on her side, a certified nurse aide (CNA) provided morning care alone, citing insufficient staffing as the reason for not having a second staff member present. During this unsupervised care, the resident fell from the bed, resulting in the dislodgement of her gastrostomy tube. The resident had a history of stroke with hemiparesis, was non-ambulatory, and was dependent on staff for bed mobility, toileting, hygiene, and bathing. The resident's care plan and assessments consistently documented the need for two-person assistance for all care, and staff interviews confirmed awareness of this requirement. The fall occurred while the CNA was changing linens and the resident was positioned on her side, leading to the resident sliding off the bed and sustaining an injury that required hospitalization for gastrostomy tube replacement.