Resident Fall Due to Unattended Incontinence Care and Failure to Use Assistive Devices
Penalty
Summary
Staff failed to provide safe care to a resident with left-sided weakness and vascular dementia during incontinence care. The resident, who was cognitively intact but dependent on staff for all activities of daily living and required bed rails for mobility, was rolled onto her left side in bed and left unattended by a nursing assistant. The bed rails were not raised, and the bed was not locked at the time. While the nursing assistant left the bedside to retrieve a clean gown, the resident, unable to support herself due to her hemiplegia and hemiparesis, rolled off the bed and fell to the floor. As a result of the fall, the resident sustained a laceration to the bridge of her nose, facial bruising, and a fractured nasal bridge. She was assessed by nursing staff, and emergency services were called. The resident was transferred to the hospital, where she received medical treatment including glue for the laceration and pain management. Imaging confirmed the nasal fracture, but no other injuries were found. The resident was discharged back to the facility the same day. Interviews and documentation confirmed that the resident was left alone on her weaker side without the use of required assistive devices, and the bed was not secured. Staff involved acknowledged the oversight, and the incident was attributed to human error. The resident, staff, and therapy personnel all indicated that leaving a resident with significant mobility impairment unattended in such a position without proper safety measures directly contributed to the fall and resulting injuries.