Failure to Follow Two-Person Assist Requirement During Incontinence Care Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the resident’s required assistance level during incontinence care, resulting in neglect and actual harm. The resident involved had multiple significant medical conditions, including sequelae of cerebral infarction with aphasia, subdural hematoma, cognitive communication deficit, muscle weakness, tracheostomy status, and chronic respiratory failure. The resident’s quarterly MDS documented a need for extensive assistance of two or more staff for bed mobility, and the physician’s orders and care plan specified bed mobility as a two-person assist and transfers with a Hoyer lift requiring two staff. On the date of the incident, a CNA (Employee E3) provided incontinence care to the resident alone, despite the documented requirement for a two-person assist. During care, the CNA positioned the resident on the left side to complete incontinence care. While in this position, the resident extended the left leg out of the bed, followed by the right leg, and began sliding out of the bed feet first. The CNA yelled for help and attempted to hold the resident in the bed by grabbing around the trunk but was unable to prevent the resident from sliding off the bed. The CNA then assisted the resident to the floor while protecting the resident’s head. A nurse responded and found the resident on the floor with the CNA kneeling behind, supporting the resident’s head and upper body. The resident was assessed, returned to bed via Hoyer lift, and initial neurological checks and vital signs were stable, with the resident initially denying pain. Subsequently, the resident reported right arm pain, and due to the recent fall, an X-ray was ordered. Radiology results showed a comminuted fracture-dislocation of the right humeral head with anteroinferior dislocation from the glenoid, generalized soft tissue swelling, and mild degenerative changes. The facility’s internal investigation included interviews with the CNA and the DON. The CNA acknowledged awareness that the resident required a two-person assist but stated she believed it would be acceptable to provide care alone because the resident could help with the left hand. The CNA also stated she did not ask anyone for help before providing care. The DON later determined that the incident should be substantiated for neglect because the CNA failed to follow the documented two-person assist requirement for bed mobility, which led to the resident’s fall and resulting fracture. The resident was described as alert and oriented but severely aphasic, flaccid on the right side with minimal use of the left side, and dependent for personal care. An attempted interview by the DON confirmed the resident remembered falling but had difficulty consistently describing the event due to aphasia. Facility documentation and the internal investigation concluded that the CNA did not follow the two-person assist policy for bed mobility as documented in the resident’s care plan, and this failure to follow established safety procedures during care constituted neglect and resulted in actual harm in the form of a right humeral head fracture.
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