Resident Left Unattended During Wound Care Results in Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, severe cognitive impairment, poor balance, and unsteady gait was left unattended during wound care. The resident was dependent for bed mobility and transfers, and her care plan identified her as at risk for falls. During a wound care procedure, the resident was positioned on her right side near the edge of the bed, with the bed elevated and no bed rails in use. While the wound care physician and a nurse were present, the nurse left the room to obtain additional supplies at the physician's request. The physician remained with the resident initially but then also left the room to gather more supplies, leaving the resident unattended in a vulnerable position. The resident subsequently fell from the bed and was found on the floor by the physician upon returning to the room. The resident was assessed for injuries, and although no injuries were observed, she was sent to the hospital for further evaluation. Interviews with staff confirmed that it was standard practice not to leave residents in unsafe positions and to ensure they were safely positioned in the middle of the bed with the bed in the lowest position before leaving them unattended. The physical therapist and nurse aide both confirmed the resident's inability to maintain balance or reposition herself safely. The incident was witnessed and reported by multiple staff, and the facility's investigation confirmed that the resident was left unattended in an unsafe position, directly leading to the fall.