Failure to Provide Adequate Supervision and Safe Repositioning Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established procedures for turning and repositioning a dependent resident, resulting in a significant accident. Two CNAs, both of whom had received in-service training on proper repositioning techniques, attempted to turn and reposition a resident who was totally dependent on staff for mobility and required two-person assistance. Both CNAs stood on the same side of the bed, contrary to facility policy and training, which required one staff member on each side of the bed to ensure safety during such procedures. The resident involved had a complex medical history, including morbid obesity, paraplegia, chronic pain syndrome, and was bedridden and unable to assist with movement. The care plan and MDS assessments clearly indicated the need for two-person assistance for all bed mobility and emphasized safety measures to prevent falls. Despite these documented needs and interventions, the CNAs repositioned the resident while both were on the left side of the bed, leaving the right side unsecured. During the maneuver, the resident slipped off the right side of the bed and fell to the floor. As a result of this incident, the resident sustained a displaced fracture of the right distal femur, a skin tear, and experienced severe pain and fear. The resident required urgent transfer to an acute care hospital for evaluation and treatment. Interviews with the CNAs, DON, and other staff confirmed that the proper technique was not followed and that the accident could have been prevented if the established safety protocols had been observed.