Failure to Provide Required Two-Person Assist During Bed Repositioning Results in Resident Fall and Head Injury
Penalty
Summary
A dependent resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, vascular dementia, and a cognitive communication deficit, experienced a fall from bed resulting in a head injury that required a staple. The resident was nonverbal and required assistance with activities of daily living. According to the facility's practice, such a resident should have been repositioned in bed with the assistance of two staff members. However, on the date of the incident, a CNA attempted to turn the resident alone, during which the resident slid off the bed and sustained a laceration to the back of the head. Interviews with facility staff confirmed that the resident was dependent and should have received a two-person assist for bed repositioning. The Assistant Director of Nursing and the Restorative Nurse both stated that dependent residents require two staff for repositioning. The resident's care plan and assessment did not specify the number of staff required for assistance, and the CNA involved in the incident was not available for interview. The incident report and progress notes documented the fall and subsequent injury, as well as the resident's return from the hospital with a staple applied to the head wound.