Failure to Provide Required Two-Person Assist During Incontinent Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for bed mobility and incontinent care was protected from a fall during care. The resident had a history of other abnormalities of gait and mobility, lack of coordination, and bilateral above-knee amputations, and was care planned as total assist x2 for bed mobility, transfers with mechanical lift, and incontinent care. During an episode of incontinent care, a CNA provided care alone. The resident became agitated and combative, and when the CNA turned to clean the resident, the resident pulled on the privacy curtain and rolled out of the bed, resulting in a fall and a small skin tear/abrasion to the forehead. The CNA reported she had routinely cared for this resident and was not aware that two-person assistance was required for bed mobility and incontinent care. She stated she had previously asked nurses whether the resident required two-person assistance and was told the resident was a one-person assist, though she could not recall which nurse provided this information. The CNA later reviewed the chart and saw the resident was documented as an extensive assist, meaning one- or two-person assistance, while the care plan and Kardex specified total assist x2 for bed mobility and incontinent care. The DON stated her expectation was that CNAs review and follow the Kardex prior to providing care and indicated that, in this incident, the Kardex directions for two-person assistance were not followed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.