Resident Fall Due to Inadequate Supervision During Bed Bath
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to conditions including functional quadriplegia, aphasia, and impaired mobility, was not provided adequate supervision during a bed bath. The resident's care plan required one-person assistance for bathing, bed bolsters, and fall mats on both sides of the bed due to a high risk for falls. Despite these interventions, the assigned CNA removed the fall mat from the left side of the bed and raised the bed to provide care. After completing the bed bath, the CNA turned away from the resident to retrieve clothing from the closet, leaving the resident unsupervised and unsecured in bed. While the CNA was turned away, the resident rolled over the bed bolster and fell from the left side of the bed onto the floor, resulting in a laceration to the forehead. The resident was not moved until EMS arrived and was subsequently transferred to the emergency room for treatment of the head injury. The resident returned to the facility with staples in place for the laceration. Several days later, after the responsible party noticed swelling and discoloration in the resident's right leg and foot, the resident was sent to the hospital again and diagnosed with a right humerus fracture and a right hip fracture, both attributed to the fall. Interviews and documentation confirmed that the CNA acknowledged turning away from the resident during care and admitted to using excessive lotion, which made the resident slippery. The CNA also recognized that all necessary items should have been within reach before starting the bed bath and that the resident should not have been left unsupervised. Staff interviews and record reviews further corroborated that the required fall prevention measures were not maintained at the time of the incident, directly leading to the resident's fall and subsequent injuries.