Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s plan of care for required assistance during bed mobility. The resident had diagnoses including rheumatoid arthritis and Huntington’s disease and required a two-person assist for bed mobility per the care plan. During continence care on January 9, 2026, a nurse aide repositioned the resident in bed without obtaining a second staff member to assist, despite the documented requirement for two-person assistance. According to the incident report and the nurse aide’s written statement, the aide did not use a second person because she could not find help, stated that everybody was with their clients, and did not want to wait because the resident was wet. During this episode of care, the resident slid with her pillow to the floor. The facility determined that the probable cause of the fall was the failure to follow the plan of care requiring two-person assistance with bed mobility, resulting in the resident not being kept free from neglect.
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