Failure to Provide Required Assistance During ADL Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident received adequate assistance to prevent falls, resulting in harm. According to the facility's policy, activities of daily living (ADLs), including incontinence care, require adherence to the care plan and appropriate staffing. The resident involved had significant medical conditions, including a history of stroke, above-the-knee amputation, and diabetes, and was care planned for a two-person assist with ADLs due to generalized weakness and physical limitations. Despite this, a nurse aide provided incontinence care alone, without the required second staff member, during which the resident fell from the bed and sustained a right hip fracture. The incident occurred when the resident, while being changed, held onto a chair that moved, causing her to roll off the bed. The nurse aide involved stated she was unaware that incontinence care was considered an ADL and did not realize a two-person assist was required for this task. Documentation in the resident's care plan and Kardex indicated the need for two-person assistance with ADLs, but this was not followed. The nursing home administrator confirmed that staff are expected to know incontinence care is an ADL and to follow the care plan. The failure to provide the required assistance directly resulted in the resident's fall and injury.