Failure to Provide Consistent Two-Person Assistance During Incontinent Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from accident hazards and received adequate supervision to prevent accidents during incontinent care. The resident, who was severely cognitively impaired, dependent on staff for bed mobility, and at high risk for falls, experienced a fall from bed during incontinent care. Documentation and assessments indicated that the resident often required two-person assistance for bed mobility and incontinent care, but there was inconsistency among staff regarding the level of assistance actually provided. Some staff reported providing care independently, while others used two-person assistance, and the care plan and documentation were not consistently aligned. On the day of the incident, a CNA attempted to reposition the resident by pulling a draw sheet while standing on the side of the bed against the wall. The resident rolled out of bed and sustained significant injuries, including a fracture of the left distal femur and a hematoma with a skin tear on the right hand. The resident was transferred to the hospital for evaluation and returned to the facility with an immobilizer and additional care needs. The incident occurred despite the presence of fall prevention measures such as a low bed, fall mat, and non-skid socks. Interviews with staff and review of documentation revealed confusion and inconsistency regarding the required level of assistance for the resident. While some staff believed the resident only needed one-person assistance, others documented and practiced two-person assistance. The facility's documentation showed that two-person assistance was provided in a significant number of care opportunities, but this was not consistently communicated or implemented among all staff, leading to the fall and resulting injury.