Failure to Provide Safe Incontinence Care Resulting in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, rheumatoid arthritis, and a history of falls was not provided incontinence care in a safe manner. The resident had recently been admitted and required assistance with mobility. During incontinence care, a CNA was the only staff member present and was informed by a nurse that the resident required one-person assistance. The resident was turned to his right side and instructed to hold onto the side rail with his left hand, despite having joint deformities and weakness in his hands due to rheumatoid arthritis. The resident became positioned very close to the edge of the bed, and the CNA was unable to move him back to the center due to his size. While the CNA was providing care, the resident reported that his hands were getting weak and indicated he could not hold on much longer. Before the CNA could respond, the resident lost his grip, fell off the bed, and sustained fractures to his toes on both feet. The incident was witnessed by the CNA, who confirmed that the resident's upper body fell over the side rail first, followed by his lower body. The resident was subsequently sent to the hospital, where multiple fractures were confirmed, and he was returned to the facility with non-weight bearing orders. Interviews with other CNAs and the Restorative RN confirmed that residents should always be positioned in the center of the bed during care to prevent falls. The Therapy Director stated that, given the resident's size and new admission status, a second staff member should have been present for safety, especially since the CNA was unable to reposition the resident alone. The facility's fall prevention policy requires the use of professional standards of practice, which were not followed in this instance.