Failure to Follow Two-Person Assistance Care Plan Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan interventions requiring two-person assistance for bed mobility and incontinence care for a dependent resident, resulting in a fall with bilateral femur fractures. The resident, admitted in 2015 with diabetes and urinary incontinence, had an MDS assessment dated 1/9/26 and a care plan indicating dependence on staff for ADLs, including bed mobility and toileting, and specifically required two-person assistance. On 2/7/26, during incontinence care, two CNAs were assisting the resident, who was positioned on their side. One CNA (Staff 5) left the room to request barrier cream from an LPN (Staff 3), leaving the other CNA (Staff 4) alone with the resident. While Staff 5 was outside the room, Staff 4 obtained and wet a washcloth at the sink with the resident still on their side. The resident then yelled that they were rolling, and Staff 4 called for help. Staff 5 and Staff 3 entered the room and found the resident on the floor. Progress notes documented that the resident was transferred to the hospital after the witnessed fall and that the hospital later reported the resident required surgery on both legs due to bilateral femur fractures. The fall report, initiated on 2/7/26 and updated on 2/9/26, confirmed the sequence of events and the resulting injuries. In interviews, multiple staff members, including CNAs, an RN, an LPN/Care Manager, and the DNS, consistently stated that the resident was fully dependent, unable to perform bed mobility, and required two-person assistance for all bed mobility and incontinence care. They further stated that for a two-person dependent resident, both staff must remain with the resident for the duration of care, and the resident should not be left on their side unattended but should be repositioned onto their back before any staff leave the room. Staff 4 acknowledged in her statement that she was the only person in the room when the resident fell and that the resident should have been rolled onto their back before she left.
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