Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, quadriplegia, multiple sclerosis, dementia, and a history of combative behaviors was not provided the required two-person assistance during incontinence care. The resident was assessed as being totally dependent on staff for toileting and bed mobility, with documented behaviors of physical and verbal aggression. Facility policy and the resident's care plan both specified the need for two staff members to be present during care due to the resident's behavioral and physical needs. On the day of the incident, only one nurse aide provided care to the resident, despite the care plan's requirement for two staff members. During the care, the resident became combative, grabbing the nurse aide's thigh with both hands. The nurse aide attempted to remove the resident's hand by moving the resident's arm, at which point a loud pop was heard and the resident cried out in pain. The resident was subsequently assessed, sent to the emergency department, and diagnosed with a closed fracture of the right humerus. The facility's internal investigation substantiated neglect, confirming that the required two-person assistance was not provided during care, which directly resulted in actual harm to the resident. Interviews with facility leadership confirmed the resident's behavioral history and the failure to follow the care plan on the day of the incident.