Failure to Follow Two-Person Assistance Care Plan Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed an individualized comprehensive care plan requiring two staff members to assist a resident with bathing, dressing, and bed mobility. The facility’s own policies stated that each resident would have an individualized, person-centered care plan developed by the interdisciplinary team, and that care plans and associated care cards would guide direct care staff in providing care. The resident’s care plan and care card both specified total dependence on two staff members for bathing, dressing, and bed mobility. The resident involved had been admitted in October 2024 with multiple diagnoses, including dementia, cerebrovascular accident with right-sided hemiparesis, osteoarthritis, coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, and muscle weakness. A quarterly MDS assessment documented that the resident was severely cognitively impaired, with a BIMS score of 00, and was dependent on staff for bathing, dressing, and bed mobility. The resident’s care plan, dated 01/09/26, and the resident care card, which served as a quick reference for direct care staff, both indicated that the resident required the assistance of two staff members for these activities. On the morning of 01/14/26, a care associate assigned to the resident provided care and attempted to dress the resident in bed without obtaining assistance from a second staff member, despite knowing from the care card and her prior experience that two-person assistance was required for bed mobility and in-bed care. While the care associate was turning the resident and pulling on the resident’s pants, the resident slid off the bed and landed face down on the floor. A nurse responded to the care associate’s call for help and found the resident face down on the floor, bleeding from a laceration above the right eyebrow. The resident was assessed, found to have a 2.5 cm laceration on the right forehead, and was transferred to the hospital emergency department, where the wound was repaired with seven sutures. Interviews with the nurse and the care associate confirmed that the care associate was alone in the room at the time of the incident and did not follow the two-person assistance intervention specified in the resident’s care plan and care card.
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