Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to implement a resident’s person-centered fall prevention care plan interventions, specifically the requirement for two staff to assist with bed mobility. The resident had diagnoses including cerebral infarct and hemiplegia affecting the left nondominant side, and a care plan dated 10/1/25 identified a self-care deficit related to weakness, limited mobility, and impaired balance, with an intervention specifying two staff assist for bed mobility. A Quarterly MDS assessment indicated the resident was cognitively intact. Despite these documented needs, only one CNA provided care during the incident. According to interviews and progress notes, the CNA stood on the left side of the resident’s bed and rolled the resident onto her right side to provide care and adjust the sheet underneath. While the resident was lying on her right side, she rolled off the right side of the bed and fell to the floor. Progress notes documented that this was a witnessed fall from bed during care, after which the resident complained of left leg pain. An X-ray later showed a fracture involving the proximal left tibia and fibula with no displacement, and the resident was sent to the hospital. Both the CNA and the LPN who responded to the fall reported they were not aware that the resident required two staff for bed mobility, despite the facility’s fall management policy indicating that person-centered fall-related interventions to address fall prevention would be implemented.
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