Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during care for a resident with significant physical and cognitive impairments. The resident, who had a history of cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness, was assessed as requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this documented need, the CNA provided care alone, turned the resident on his side, and the resident subsequently rolled off the bed, sustaining a laceration to the forehead that required hospital treatment. The incident was witnessed and documented by nursing staff, who responded to the scene and provided immediate care, including applying pressure to the wound and arranging for hospital transfer. Interviews with staff revealed that the CNA was unaware of the resident's two-person assist requirement and had not checked the Kardex or care plan prior to providing care. Other staff members, including nurses and administrative personnel, confirmed that the resident's care plan and Kardex indicated a two-person assist was necessary, and that the CNA did not request help as required by facility policy. Further investigation showed that the CNA had a history of working with the resident and had previously provided care alone, indicating a lack of adherence to established protocols. The Director of Nursing (DON) and Administrator acknowledged that the CNA did not follow the care plan and facility policy, and that there was a failure to ensure staff were consistently aware of and following residents' required levels of assistance. The incident resulted in the resident sustaining an injury due to inadequate supervision and assistance during care.