Failure to Provide Required Supervision and Assistance During Resident Care Resulting in Fall
Penalty
Summary
A resident with quadriplegia, anxiety, muscle wasting, and moderate cognitive impairment, who required two-person assistance for bed mobility and transfers, experienced a fall while being cared for by a single CNA. The resident became anxious during care, attempted to hold onto the bed sheet, and subsequently rolled off the bed, resulting in a laceration above the right eyebrow and additional injuries. The resident was transported to the hospital for evaluation and treatment following the incident. Review of the resident's care plan and ADL documentation confirmed the need for two-person assistance during bed mobility and toileting. However, at the time of the fall, only one CNA was present and providing care. The facility's Accident and Injury policy, provided upon request, did not address specific procedures for fall prevention. Interviews with staff and the DON confirmed the circumstances of the fall and the lack of adherence to the resident's care plan requirements.