Failure to Provide Adequate Supervision and Assistance Leads to Preventable Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, who required extensive assistance for all activities of daily living (ADLs), experienced a preventable fall resulting in a closed fracture of the distal end of the left femur and pain. The resident was dependent on staff for bed mobility and toileting, with care plans and the Kardex specifying the need for two-person assistance for both tasks. Despite these documented requirements, a certified nursing assistant (CNA) provided incontinence care alone, during which the resident rolled off the bed and sustained multiple injuries, including skin tears and a fracture. The facility's investigation revealed that the CNA misunderstood the difference between bed mobility and toileting assistance, believing that only one person was needed for toileting care, even though the resident was being cared for in bed. Documentation in the care plan and Kardex consistently indicated the need for two-person assistance for both bed mobility and toileting, but there was also a contradictory intervention stating dependency with one staff, which may have contributed to the confusion. The interdisciplinary team failed to identify and resolve these conflicting interventions, resulting in unclear and imprecise guidance for staff. Interviews with facility staff, including the CNA involved and the Administrator, confirmed that the CNA was aware of the two-person requirement for bed mobility but not for toileting, and proceeded to provide care alone. The Administrator acknowledged the oversight in the investigation and the failure to ensure that clear and precise interventions were implemented to maintain resident safety and prevent accidents. The facility's policy required systematic identification and mitigation of hazards, but this was not effectively carried out in this case.