Failure to Follow Two-Person Assist Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a cerebral infarction, who required two-person assistance for bed mobility, was left in the care of a single non-licensed staff member during incontinence care. The resident's care plan and Minimum Data Set (MDS) both specified the need for two staff members to assist with bed mobility, but this protocol was not followed. During the care, the staff member attempted to manage soiled linens and clean the resident alone, despite the resident's repeated attempts to roll and complaints of hip pain. While the staff member was distracted by picking up a sheet that had fallen to the floor, the resident rolled off the bed and fell onto the floor. The bed was in a high position at the time to facilitate incontinence care. The fall resulted in significant injuries, including a closed displaced fracture of the first and second cervical vertebrae, a cervical compression fracture, a subdural hematoma, and a scalp laceration, all of which required hospitalization. Facility documentation and interviews confirmed that the staff member did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The incident was substantiated as neglect, as the failure to provide the required level of assistance directly led to the resident's injuries.