Failure to Prevent Resident Injury During Bedside Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including severe cognitive impairment, hemiplegia, hemiparesis, osteoporosis, and a high risk for falls, was not adequately protected from accident hazards during care. The resident required maximal assistance for activities of daily living and was dependent for bed mobility. While being assisted with dressing by a CNA, the resident was positioned at the edge of a low bed with a Chux pad underneath, which contributed to the resident sliding off the bed and onto the floor. The CNA acknowledged that sitting the resident at the edge of the bed with a Chux pad was a mistake, as it made the surface slippery and difficult to control the resident's movement. Following the incident, the resident initially did not complain of pain, but later developed significant right hip pain. Assessment and interviews revealed that the resident had sustained a minimally displaced right intertrochanteric hip fracture as a result of the fall. The resident's care plan had identified a high risk for falls and set a goal to prevent falls, but the interventions in place were not sufficient to prevent this incident. Staff interviews indicated that the bed was kept in a low position during care, which made it difficult for the CNA to maintain balance and safely assist the resident, and that the use of a Chux pad further increased the risk of sliding. Documentation and communication following the fall were inconsistent, with pain medication administered "in case" of pain and pain levels documented that did not match the resident's reported symptoms at the time. The facility's policies and procedures on fall risk and prevention emphasized the need for individualized interventions and proper assessment of risk factors, but these were not effectively implemented in this case. The failure to provide adequate supervision and to ensure a safe environment directly resulted in the resident's injury, decreased mobility, and increased pain.