Failure to Provide Required Two-Person Assistance During Incontinence Care Leading to Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for one resident, identified as R11. The resident was admitted with multiple diagnoses including Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right hip ORIF. An MDS dated 10/24/25 documented that these diagnoses remained current, and another MDS indicated that the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning left and right in bed. Multiple staff interviews confirmed that substantial/maximal assistance meant two staff were required to perform the task. The resident also had an order dated 1/16/19 for bilateral enabler bars for positioning. A progress note dated 8/22/25 documented that at 5:10 a.m. a nurse was called to the resident’s room and found the resident on the floor on her left side. Facility documentation showed that a nurse aide (Employee E9) 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 this time, the resident rolled out of bed and fell. The documentation did not state whether the ordered enabler bars were in use at the time of the fall, and there was no documented investigation into why the nurse aide attempted to provide care alone when the resident had been identified as requiring the assistance of two staff. The Nursing Home Administrator and DON confirmed that the facility failed to ensure the resident received proper assistance and supervision, resulting in pain and the need for X‑rays to rule out injury or fractures.
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