Failure to Provide Adequate Supervision and Safe Positioning During Incontinent Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and safe positioning for a resident during incontinent care, resulting in the resident falling from her bed. The resident, an elderly female with multiple diagnoses including cerebrovascular disease, metabolic encephalopathy, right-sided weakness, dysphagia, malnutrition, abnormal posture, rheumatoid arthritis, seizures, and a history of traumatic brain injury, required substantial to total assistance with activities of daily living (ADLs) and was always incontinent of bladder and bowel. Her care plan and assessments indicated significant cognitive and physical impairments, including dependence on staff for transfers and repositioning, and a need for close supervision during care. On the day of the incident, the CNA was observed on in-room surveillance video providing perineal care while the resident was on her side. The CNA instructed the resident to roll, and although the resident attempted to comply, her body was not properly aligned or secured on the bed. The CNA removed bed linens and, while doing so, the resident's legs slipped off the bed. The CNA then turned away from the resident, at which point the resident's body followed her legs off the bed, resulting in a fall. The resident struck her head and sustained a right distal femur fracture and dislodgement of her feeding tube. The CNA immediately picked the resident up from the floor and placed her on the bed, contrary to standard protocol for post-fall management. Interviews and record reviews revealed that the CNA had a history of not following proper infection control and peri care procedures, including not using appropriate personal protective equipment (PPE) and not maintaining hand hygiene. The CNA had received annual competency training and signed off on relevant in-services, but had been previously counseled for similar issues. At the time of the incident, the resident was on contact isolation for C. difficile, and the CNA was not wearing full PPE. The incident was witnessed by staff and documented in facility records, with the resident subsequently transferred to the hospital for evaluation and treatment.