Failure to Follow Two-Person Assistance Requirements During Incontinent Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate physical assistance and supervision during incontinent care for a resident who was dependent on staff for toileting, personal hygiene, and bed mobility. The resident had multiple diagnoses, including osteoarthritis, congestive heart failure, chronic kidney disease, dementia, cardiomyopathy, and polyneuropathy, and was assessed as cognitively intact but with impairments in both upper and lower extremities. His care plan and ADL documentation indicated he was totally dependent on two staff for bed mobility, including use of a draw sheet to move him in bed, and dependent on staff for toilet hygiene and personal hygiene. A fall risk assessment score of 12 identified him as at risk for falls. On the date of the incident, one CNA provided peri-care to the resident while he was in bed, despite the care plan and Kardex indicating he required two-person assistance for bed mobility and toilet hygiene. During this care, the CNA rolled the resident onto his left side, away from her, to clean him. While in this position, the resident’s hand lost strength and he fell from the bed to the floor. At the time of the fall, only one aide was assisting him, and the LPN on duty later confirmed she was not aware of his staffing care levels but acknowledged that only one aide had been providing care when the fall occurred. Following the fall, the resident reported significant pain in his right arm, and a hard lump was noted near his right elbow. Subsequent hospital imaging confirmed multiple fractures: a right distal humerus supracondylar traverse closed fracture, a right coronoid non-displaced fracture, a left distal femur supracondylar closed fracture, and a left patella fracture, with documentation stating these injuries occurred when he slipped off the bed while his brief was being changed. The DON confirmed that the resident’s records and care plan had long indicated the need for two-person assistance for bed mobility and toilet hygiene, and the resident reported that only about half the time were two staff present during incontinent care or cleaning in bed. The facility’s fall prevention policy required assessment and care planning for fall risk, but the resident’s established need for two-person assistance was not followed at the time of the incident, resulting in the fall and injuries.
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