Resident Fall Due to Improper Linen Change Technique
Penalty
Summary
Wyncote Care Center was found to be non-compliant with the requirement to maintain a resident environment free of accident hazards, as evidenced by an incident involving a resident falling from bed during care. The facility's policy on fall management emphasizes the need to identify and mitigate hazards and risks, yet the incident occurred when a nurse aide was changing the resident's bed linens. The resident, who had diagnoses of lack of coordination, unsteadiness on feet, obesity, and muscle weakness, required substantial assistance for transfers and moderate assistance for bed mobility. During the linen change, the resident was turned away from the aide, and while the aide was changing the sheets, the resident rolled over the sheets and fell to the floor, resulting in severe right-side pain. The facility's investigation revealed that the bed was in a high position, and the resident was holding onto a side rail when her hands slipped, leading to the fall. The nurse aide involved stated that she was performing a complete bed change and had turned the resident towards the door with the side rails up. The Director of Nursing confirmed that the appropriate technique for changing linens with a resident in bed was not followed, which contributed to the accident. The resident was transported to the hospital for evaluation and returned with complaints of discomfort in the right shoulder.
Plan Of Correction
1. R1 was re-assessed by rehab and care planned updated for 2 person assist. Resident is currently on restorative care services. 2. ADON/DON to audit incident reports within the last 60 days. Residents affected will be re-assessed and care plans will be updated according to outcome. Interdisciplinary team will be consulted in order to develop comprehensive care plan updates. Completion Date: 5/30/2025 3. DON/ED provided all care staff with in-service & educated on policy's & procedures specific to bed mobility. Completion date: 4/25/2025 4. ADON/DON have ongoing audits of incident reports, and present any trends or decline to the ED/IDT during daily clinical meeting, weekly UR meeting, and weekly risk management meetings to ensure an ongoing review of potential risks & identifying/implementing interventions proactively. Completion Date: 5/30/2025