Resident Left Unattended During Care Results in Fall and Multiple Fractures
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for bed mobility, repositioning, and incontinence care, was left unattended during care. The resident had significant medical conditions, including peripheral artery disease with bilateral foot gangrene, diabetic neuropathy, acute lymphoblastic leukemia in remission, chronic pain, and chronic urinary retention with an indwelling catheter. The care plan and therapy assessments indicated the resident required total assistance for all activities of daily living, including bed mobility and repositioning, and was at risk for slipping or tilting to one side if not properly supported. On the night of the incident, the resident activated the call light and requested to be changed. A nurse responded and informed a CNA, who then entered the resident's room, asked what was needed, and left the resident on their side to retrieve supplies for incontinence care. The CNA reported being out of the room for approximately 2-3 minutes. When the CNA returned, the resident was found on the floor, having fallen from the bed. There was no bed rail in place to assist the resident in maintaining position, and the bed was positioned near a concrete ledge under the window, which the resident struck during the fall. The resident sustained multiple injuries, including a left scalp abrasion, fractures of the left superior and inferior pubic ramus, left scapula, and left clavicle, and required hospitalization for six days. Interviews with staff confirmed the resident's total dependence for mobility and the need for careful repositioning. The facility's policy required immediate interventions and corrective actions to prevent recurrence, but the necessary supervision and assistance were not provided at the time of the incident.