Failure to Provide Adequate Supervision During Incontinence Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for care due to left-sided weakness from a stroke and was described as a larger individual, fell out of bed during incontinence care. The resident required significant assistance for bed mobility and incontinence care, as she was unable to support herself or roll independently. Despite this, only one CNA was present during the provision of incontinence care, and the resident rolled out of bed, landing on her knees and later being diagnosed with a left femoral neck fracture. Interviews with staff revealed that the determination of whether one or two CNAs were needed for incontinence care was based on the resident's size and bed mobility, but this information was not clearly communicated or documented in the care guide. The CNA providing care at the time of the incident was not informed that two staff members were required for this resident, and the care guide only indicated the need for one staff member for bed mobility, not specifically for incontinence care. Multiple staff members, including the LPN, unit manager, and other CNAs, stated that two staff should have been present due to the resident's condition and inability to support herself. The facility's policies on urinary incontinence did not address the assessment of the level of staff assistance required for incontinence care. As a result, there was a lack of clear guidance and communication regarding the appropriate staffing needed to safely provide care for residents with significant mobility limitations, directly contributing to the resident's fall and subsequent injury.