Failure to Provide Required Two-Person Assistance and Positioning Safety During Incontinence Care
Penalty
Summary
The facility failed to protect a resident from neglect when a nurse aide provided incontinence care alone to a resident who required the assistance of two staff for bed mobility. The resident had diagnoses including Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right hip ORIF, and the MDS documented that the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning in bed. Multiple staff, including nurse aides and an LPN, confirmed that substantial/maximal assistance meant two staff were required to perform the task. The resident also had an order for bilateral enabler bars for positioning. A progress note documented that the nurse was called to the resident’s room early in the morning and found the resident on the floor on her left side. Facility documentation showed that the nurse aide had entered the room alone to provide incontinence care, turned the resident onto her side, and then left the resident in that position while going into the bathroom to wet a towel, during which time the resident rolled out of bed. The documentation did not show that the resident was protected from neglect, did not address whether the ordered enabler bars were in use, and indicated that the physician was called and X‑rays were ordered to rule out possible injury or fracture after the resident complained of pain. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to protect the resident from neglect, resulting in pain and the need for X‑rays.
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