Failure to Provide Adequate Supervision and Assistance During Incontinence Care Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance and interventions to prevent a fall with injury for a resident who had multiple medical conditions, including anemia, diabetes, stroke, sacroiliitis, difficulty walking, abnormal posture, and advanced kidney disease. The resident was identified as being at risk for falls and required partial to moderate assistance for bed mobility, with care plans specifying the use of bedrails and staff assistance during transfers and ambulation. Despite these documented needs, during incontinence care, a nurse aide turned the resident away from her and left the resident unattended on the bed while reaching for supplies, resulting in the resident rolling out of bed. At the time of the incident, bedrails were not in place, contrary to the resident's care plan and facility policy. As a result of this lapse in supervision and failure to follow established protocols, the resident sustained significant injuries, including a subarachnoid hemorrhage, a scalp laceration requiring six sutures, and a C4 vertebrae fracture. Staff interviews confirmed that proper procedures, such as using bedrails or turning the resident toward the caregiver, were not followed. Facility leadership acknowledged that adequate assistance and interventions were not provided to prevent the fall and resulting harm.