Failure to Provide Required Two-Person Assist During Incontinence Care Resulting in Fall and Leg Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure required two-person assistance during incontinence care and bed mobility for a resident, resulting in a fall from the bed and subsequent injury. The resident, who had diagnoses including congestive heart failure, morbid obesity, and abnormal posture, had an MDS indicating intact cognition and an active care plan specifying extensive two-person assist for toileting (check/changes and bedpan) and bed mobility. Despite this, the resident reported that a CNA, identified by the resident as CNA A, attempted to perform an incontinence brief change alone, stating they were strong enough and did not need help. During this care, the CNA rolled the resident onto their left side, and the resident fell off the opposite side of the bed. The resident described experiencing significant pain, hitting their head, and sustaining a large leg laceration that required hospital treatment and suturing. Facility documentation and staff interviews corroborated that only one staff member was providing care at the time of the fall, contrary to the resident’s care plan. A progress note by an LPN on the date of the incident documented that the resident was found slightly on their right side, bleeding from behind the left ear and from the left lower extremity. The LPN confirmed their understanding that the resident required two-person assistance for brief changes, and the DON acknowledged that the care plan specified extensive two-person assist for check/changes and bed mobility, in addition to addressing behavioral concerns. The resident’s medical record showed that the leg laceration became infected and required IV antibiotics, surgical debridement, a wound vac, continued wound care, and oral pain medication. The Administrator stated that the expectation was for staff to follow the plan of care regarding assistance levels during care.
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