Failure to Follow Two-Person Assist Requirements Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents. A male resident with diagnoses including immobility syndrome (paraplegic), generalized muscle weakness, cognitive communication deficit, contractures, dysphagia (oral phase), hyperlipidemia, and a need for assistance with personal care was admitted on an unspecified date. His MDS assessment showed he required supervision and two-person assistance with bed mobility, transfers, toileting, dressing, and personal hygiene, and his care plan documented that he was at risk for falls and required two-person assistance with all ADLs except eating. On the date of the incident, a CMA (CMA-A) was providing personal care to this resident. According to CMA-A’s signed statement, the resident became agitated during care, so she stopped to calm him. After he calmed down, she resumed care, but the resident became agitated again, and as she was wiping him, he fell from the bed to the floor, landing face down and on his left side. CMA-A reported observing blood and calling for help. The facility’s Provider Investigation Report later documented that CMA-A had provided care to the resident alone, despite the care plan requirement for two-person assistance, and that the resident rolled out of bed onto the floor during this episode of care. As a result of the fall, the resident sustained a laceration to his upper lip. Hospital records documented a diagnosis of a fall with an upper lip laceration, and the resident received stitches to treat the injury. A progress note recorded that he returned to the facility with one stitch to his upper lip following the fall. During interviews, the Administrator and ADON stated that the resident was supposed to receive two-person assistance for care, that this requirement was reflected in the Kardex and care plan, and that CMA-A did not follow these directions when providing care at the time of the fall.
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