Resident Fall Due to Improper Bed Mobility During Care
Penalty
Summary
A resident with a history of osteomyelitis of the vertebra, ventilator dependence, and significant impairment in both upper and lower extremities on one side was identified as high risk for falls and disoriented to person, place, time, and situation at all times. While receiving care from a CNA, the resident was being repositioned in bed for a brief change. The CNA rolled the resident away from herself, contrary to expected practice, and did not notice that the resident was too close to the edge of the bed. As a result, the resident rolled off the bed, landing on her knees and coccyx, which led to uncontrolled pain and required hospital evaluation and treatment. Facility records and interviews confirmed that only one CNA was present during the incident, and the facility did not have a policy or procedure regarding bed mobility or turning residents while in bed. The root cause analysis by the interdisciplinary team identified that the CNA miscalculated the resident's roll during care, leading to the fall. The facility's policy on safety and supervision emphasized making the environment as free from accident hazards as possible, but this was not achieved in this instance.