Resident Fall and Fractures Due to Inadequate Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of osteitis deformans and poor bone quality, who was bedbound and required substantial/maximal assistance for mobility and incontinence care, was not provided adequate supervision and assistance during incontinence care. The resident's care plan and MDS indicated the need for two staff members to assist with rolling and hygiene activities. However, on the day of the incident, a single CNA attempted to change and roll the resident alone. During this process, the resident's legs, described as heavy and difficult to manage, slid off the bed due to the slippery air mattress and lack of control, resulting in the resident falling to the floor. Multiple staff interviews confirmed that the resident required two-person assistance for such care, and the CNA involved acknowledged she was alone at the time. The fall led to the resident sustaining bilateral femur fractures, as confirmed by clinical notes, hospital records, and an orthopedic surgeon. The incident was directly linked to the failure to follow the required two-person assist protocol for a resident with significant mobility limitations and high risk for injury.