Resident Fall Due to Inadequate Supervision During In-Bed Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident was safe from a fall during in-bed care. The resident, who had diagnoses including COPD, Alzheimer's disease, left below-knee amputation, and legal blindness, required substantial to maximal assistance with bed mobility. While changing the resident's brief, the CNA instructed the resident to turn away from her and then moved to the opposite side of the bed. During this process, the resident turned and fell off the bed headfirst. The resident sustained discoloration to the top of the head with pain, discoloration to the left cheek, and a skin tear to the left elbow, necessitating transfer to the hospital for evaluation. Interviews and record reviews confirmed that the resident was at high risk for falls due to impaired balance, poor coordination, amputation, non-ambulatory status, sensory deficits, and cognitive impairment. Staff familiar with the resident indicated that two-person assistance was preferred for repositioning, and that residents should be turned toward staff to prevent falls. The incident was witnessed and reported, and the facility's policy required identification of possible causes within 24 hours of a fall.