Resident Fall Due to Improper Positioning During Care
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia and hemiparesis following a stroke, who required partial assistance with bed mobility, fell from bed during care. The resident, who had moderate cognitive impairment, was being assisted by a CNA who, while changing the sheets, pulled on the fitted sheet to turn the resident away. This action caused the resident to roll out of bed and fall to the floor, resulting in a large hematoma and extensive bruising on the face. The resident reported that they were told to roll over and subsequently fell. Review of the facility's policy for turning a resident on their side indicated specific steps for safe repositioning, including the use of proper body mechanics and hand placement. The CNA did not follow these procedures, as confirmed by the DON, who stated that adherence to proper procedures could have prevented the fall and injury. The incident was documented in the resident's medical record and confirmed by interviews with staff.