Failure to Provide Required Two-Person Assistance Resulting in Resident Hand Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for all care and transfers was provided that level of assistance, resulting in injury. The resident had multiple diagnoses including rheumatoid arthritis, fibromyalgia, muscle weakness, neurocognitive disorder, and hypertension, and an MDS BIMS score of 99 indicating severe cognitive impairment. Physician orders in the record specified “2 Person Assist at all Times for Safety” and “Mechanical Lift Transfers with 2 Person Assist for Safety using a Large Sling Pad.” These requirements were reflected on the CNA Direct Caregiver Form and on the CNA assignment sheet, which coded the resident as needing a mechanical lift with large sling and assistance of two staff. On the date of the incident, CNA assignment records for the 7:00 AM–3:00 PM shift listed the resident under a specific CNA’s assignment with codes indicating mechanical lift and assist of two. The CNA Direct Caregiver Form also documented the two-person assist requirement and included an FYI notation, but the box for that shift was not initialed. Interviews with the regular unit LPN and the resident’s regular CNA confirmed that the resident was total care, required two-person assistance for care and mechanical lift transfers, and that this information was communicated through the assignment sheets and caregiver forms. Staff also reported receiving regular education on care and transfers, including mechanical lifts. Despite these documented requirements and staff awareness, the investigation found that CNA #1 provided care to the resident alone, with CNA #2 only assisting with the mechanical lift transfer. CNA #1 acknowledged knowing that the resident required two-person assistance for care but proceeded to provide care independently. Subsequently, CNA #1 reported to the nurse that the resident had a skin tear on the right hand. Assessment by the RN identified a 2 cm x 0.5 cm skin tear on the right hand and a 1.4 cm x 0.5 cm laceration on the right pinky finger. The resident was later evaluated in the ER and returned with four stitches and a splinted hand, with documentation of a laceration and a fracture of indeterminate age to the fourth finger, establishing that the facility did not ensure the resident’s environment and supervision were free from accident hazards as required.
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