Failure to Provide Required Two-Person Assistance During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide the required two-person assistance during incontinent and bed mobility care for a resident with severe cognitive impairment and significant physical limitations. The resident, who had diagnoses including Parkinson's disease with dyskinesia, osteoporosis, and arthritis, was fully dependent on staff for all activities of daily living (ADLs) and had a care plan specifying two-person assistance for bed mobility, bathing, and toileting. Despite being aware of the care plan requirements, the CNA proceeded to provide care alone, citing concerns about the resident's dignity and the urgency of cleaning due to excessive soiling. During the incident, the CNA attempted to log roll the resident on an air mattress, which caused the resident to slide and fall from the bed. The CNA immediately checked on the resident and called for help. The resident was assessed and sent to the emergency room, where no major injuries were found. The CNA acknowledged in both verbal and written statements that she was aware of the two-person assist requirement but chose to act alone due to the situation at hand. Interviews with other CNAs and nursing staff confirmed that the standard procedure was to review the care plan at the start of each shift and to always use two-person assistance for this resident. Staff emphasized that deviating from the care plan could compromise resident safety. The incident was witnessed by a licensed vocational nurse (LVN), who responded to the call for help and confirmed that the CNA was alone with the resident at the time of the fall. The facility's policy required necessary assistance to maintain resident safety at all times, which was not followed in this case.