F0689

G

Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall and Fractures

Saint Clair, Missouri Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided, resulting in a fall and injury. The resident’s quarterly MDS dated 02/17/26 documented cognitive impairment, impairment of both upper and lower extremities, dependence on staff for toileting, bathing, dressing, rolling in bed, and transfers, and a history of a fall with major injury since admission or prior assessment. The resident’s care plan, revised 02/18/26, documented diagnoses including severe weakness or total paralysis of one side of the body, weakness causing limited mobility, loss of balance, muscle fatigue, and difficulty grasping objects. The care plan further documented that the resident was at risk for falls due to inability to control his/her body and poor personal safety awareness, and required two staff assistance for daily care, including bed mobility, due to bilateral hand contractures and paralysis of all four limbs and the torso.

On 02/08/26, nursing notes documented that at 3:05 P.M. a CNA notified an LPN that the resident had fallen from the bed to the floor. Staff documented the resident was found on the floor next to the bed on the left side, complaining of severe pain in the left lower extremity, with injury and deformity noted to that extremity. The facility’s investigation documented that the administrator was notified that the resident had fallen from the bed and was sent to the hospital for knee swelling and pain. The investigation further documented that the DON became aware that the CNA was alone in the resident’s room at the time of the fall, and that the nurse had exited the room while the CNA continued to provide care.

Interviews clarified the sequence of events and staff actions leading to the fall. The administrator stated that the LPN and CNA were assisting with changing the resident’s adult brief when the LPN went into the hallway to the treatment cart, and the CNA continued care; the resident’s legs slid off the bed and the resident fell. The LPN reported that the resident required two staff for all care and had no side rails, and that after providing catheter care, the LPN stepped into the hallway to the medication cart without telling the CNA that he/she would return immediately; the CNA then reported the fall. The CNA stated that the resident required one staff for peri care and dressing and two staff for transfers, and that both he/she and the LPN had been in the room to provide treatments, peri care, and to get the resident out of bed. The CNA reported that after the LPN stepped into the hallway, the resident had a bowel movement, and the CNA began cleaning the resident and assisted the resident to roll onto the left side; the resident then began to slide off the left side of the bed, and despite the CNA’s attempt from the right side of the bed to prevent the fall, the resident fell to the floor. The CNA stated he/she knew the resident was a two-person assist for transfers but did not know it was two-person assist for all care. Hospital records from 02/08/26 documented diagnoses of a fracture near the end of the thigh bone adjacent to an orthopedic implant and a tendon tear fracture of the left kneecap.