Resident Fall Due to Unsecured Mattress Overlay and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who required staff assistance for bed mobility and care, fell out of bed while receiving personal care and sustained multiple injuries, including a laceration to the forehead, skin tears, and bruising. The resident was dependent on staff for bed mobility, dressing, and hygiene, and had significant physical limitations due to diagnoses such as respiratory failure, dementia, and stroke. The resident was also on hospice care and used an air mattress overlay on top of a regular mattress, which was reported by staff to shift on the bed. On the day of the incident, a CNA was providing care and rolled the resident onto their side. The CNA then turned away from the resident to retrieve additional supplies from a bedside table, during which time the resident slid off the bed and fell to the floor. The CNA admitted to not having all necessary supplies at the bedside before starting care and did not request additional assistance, despite the mattress overlay shifting and the resident's dependency for mobility. The CNA had previously repositioned the air mattress overlay multiple times during the shift but had not reported the issue to anyone. The facility did not have a policy for monitoring residents using air mattresses or mattress overlays. Interviews with staff and leadership confirmed expectations that supplies should be prepared in advance and that staff should seek help when needed. The physical therapy evaluation did not specify the number of staff required for bed mobility, and the care plan indicated only one staff member was needed for repositioning and turning. The lack of a secure mattress overlay and insufficient supervision during care contributed to the resident's fall and subsequent injuries.