Resident Injury Due to Improper Positioning and Lack of Assistance During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure the safe positioning of a resident during personal care in bed, resulting in actual harm. The resident, who had a history of left femur fracture, vascular dementia, left-sided hemiplegia, and was dependent on staff for all activities of daily living, required two-person assistance for transfers and repositioning, as well as the use of a mechanical lift. During morning care, the CNA attempted to turn the resident toward the wall to place a brief under her, but did not position her correctly, causing her legs to begin sliding off the bed. Instead of calling for assistance when the resident was in a compromised position, the CNA attempted to resolve the situation alone. The CNA unlocked and moved the bed to gain better access, which resulted in the resident's lower body falling off the bed due to gravity. The CNA then lowered the resident's upper body to the floor. The resident sustained a left hip fracture, a small scalp laceration, an abrasion to the right forearm, and a bruise with eye bleed to the left eye as a result of the fall. The incident was confirmed through medical record review, incident reports, root cause analysis, hospital records, and interviews with staff, the resident, and a visitor. The root cause analysis identified human error, specifically the CNA's failure to follow proper procedure for positioning and not seeking assistance when needed. The resident was subsequently sent to the hospital, where imaging confirmed a displaced fracture of the left femoral neck.