Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fractures
Penalty
Summary
A deficiency occurred when staff failed to ensure the safety of a dependent resident during incontinence care, resulting in the resident sustaining fractures to both legs. The resident, an elderly female with multiple complex medical conditions including end stage renal disease, chronic respiratory failure, stroke, and dependence on renal dialysis and supplemental oxygen, was identified as being at high risk for falls. Her care plan specified that she required substantial to maximal assistance for bed mobility and transfers, including the use of a mechanical lift and the presence of two staff members for certain activities. The care plan also indicated that bed rails should be used for safety during care. On the day of the incident, the resident was being changed in bed by a single aide, contrary to the care plan's requirement for two-person assistance. Multiple staff interviews confirmed that the aide did not ensure both bed rails were up, which was necessary for the resident's safety due to her poor trunk control and inability to maintain balance. During the care, the resident rolled or slid off the bed and landed on her knees. The aide did not immediately call for help but left the resident to seek assistance, and the resident remained on the floor until additional staff arrived to help her back into bed. The resident complained of pain, and subsequent assessment and hospital evaluation revealed fractures to her left tibia and right femur. Staff interviews revealed inconsistent knowledge of the resident's care requirements, with some aides unaware that two-person assistance was needed. The incident highlighted lapses in following the resident's individualized care plan, inadequate supervision, and failure to implement necessary safety interventions during incontinence care, directly leading to the resident's injuries.