F0689

G

Failure to Follow Two-Person Assist Care Plan During Bed Bath Resulting in Fall and Fractures

Hobbs, New Mexico Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during personal care, resulting in a fall with injury. The resident was admitted with multiple diagnoses including chronic systolic heart failure, major depressive disorder, morbid obesity, type 2 diabetes mellitus, and generalized muscle weakness. Her care plan, revised on 06/03/25, specified that she required two-person assistance for bathing/showering, bed mobility, dressing, toilet use, and transfers with a Hoyer lift. On 12/27/25, progress notes documented that the resident was in her room with her husband and requested a bed bath. During this bed bath, she fell from her bed, sustained a laceration to her left pinky finger, and complained of pain to her left arm, leg, and hip.

Interview with CNA #2 revealed that he responded to the resident’s request for a bed bath and provided care while positioned on one side of the bed. During the bath, the resident rolled toward the opposite side of the bed, and CNA #2 was unable to prevent her from rolling out of the bed, resulting in her fall to the floor. CNA #2 stated he assisted the resident without a second staff member because he was unaware that she required two-person assistance as outlined in her care plan. The DON stated that residents who require two-person assistance are expected to receive help from two staff members and that CNA #2 should have been informed of this requirement during shift report. Hospital records later documented that the resident was admitted with a displaced oblique fracture of the distal femur and a displaced fracture of the middle phalanx of the fifth finger and underwent surgery to repair these fractures.