Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan requiring the assistance of two staff members for turning and repositioning. The resident, who had multiple sclerosis resulting in significant immobility and dependence on staff for all activities of daily living, was being cared for by a single nursing assistant during a bed mobility task. Despite the care plan specifying two-person assistance for mobility and repositioning, the nursing assistant proceeded alone, resulting in the resident sliding and rolling out of bed. The resident's medical history included multiple sclerosis, bilateral upper and lower extremity impairments, and complete dependence on staff for mobility and toileting. At the time of the incident, the resident was unable to control or move her legs and had no trunk control, making her highly vulnerable during transfers and repositioning. During the incident, the nursing assistant attempted to reposition the resident, but her legs slipped off the bed. The assistant tried to prevent injury by catching the resident's upper body, but was unable to prevent her from falling to the floor. As a result, the resident sustained a right tibia and fibula fracture and a distal end fracture of the left femur. Interviews with staff revealed that other nursing assistants were aware that the resident required two-person assistance for turning and repositioning due to her lack of motor control. The care plan had clearly indicated this requirement, and staff acknowledged that it would not be safe or appropriate for one person to perform these tasks alone. The incident occurred because the care plan was not followed, leading to actual harm to the resident.