Resident Required to Self-Lift After Fall, Causing Anger and Embarrassment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when a licensed nurse required the resident to get up from the floor without assistance after an unwitnessed fall. The resident had a history of cerebral infarction with sequelae and depression, used a wheelchair and walker, and required staff assistance with all ADLs, including transfers and toileting. His care plan identified him as at risk for falls related to weakness and high‑risk medications and directed staff to carry out all interventions to prevent falls and to provide partial to moderate assistance with toilet use, transfers, and bed mobility. Despite these documented needs, after the resident experienced an unwitnessed fall while attempting to self‑toilet and was found sitting on the floor leaning against his bed, staff did not physically assist him up. Nursing documentation showed that staff replaced the resident’s slick socks with gripper socks and slippers, then encouraged him to turn around, get on his knees, and pull himself up from the floor into bed. Official statements recorded that a CMA heard the nurse state she made the resident remain on the floor “to teach him a lesson” while she completed tasks and then made him get off the floor without assistance. Another statement documented that the resident reported the nurse told him to get into a “prayer position” and pick himself up, and that she was upset and argued with him about how many falls he had. During interview, the resident confirmed that the nurse instructed him to get into a praying position and get himself off the floor without her assistance, which made him feel angry and very embarrassed. Other staff interviewed indicated that they would have assisted a resident up from the floor and notified the nurse, and administrative staff characterized the nurse’s actions as inappropriate.
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