Failure to Provide Adequate Supervision During Bed Bath Results in Resident Fall and Injuries
Penalty
Summary
A resident with multiple complex diagnoses, including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis, was admitted to the facility and assessed as a moderate fall risk. The resident's care plan specified the need for two staff members for repositioning and turning in bed, while only one staff member was required for brief changes and use of the bed pan. Despite these documented care needs, the resident reported that typically only one staff member provided care, including bed baths. During an incident in February, a CNA was providing a bed bath to the resident after a bowel movement. The CNA rolled the resident onto her right side to clean her and then turned away to get more washcloths. While unattended, the resident rolled off the bed and fell to the floor. The CNA acknowledged checking the kardex for toileting and transfer assistance but did not recall checking the bed mobility assistance requirement. The resident sustained multiple rib fractures, a hip fracture, and additional complications, requiring hospitalization. Documentation and interviews confirmed that only one staff member was present during the bed bath, contrary to the care plan's requirement for two staff during bed mobility. The CNA received a final written warning for failure to follow policies, procedures, or regulations, though the specific infraction was not detailed in the personnel file. The incident resulted in significant injury to the resident, as confirmed by hospital records and staff interviews.