Failure to Provide Adequate Supervision and Safe Positioning During Incontinence Care Resulting in Resident Injury
Penalty
Summary
Facility staff failed to safely and properly position a resident in bed during incontinence care, resulting in an accident that caused actual harm. The resident involved had significant medical conditions, including end stage renal disease, a left below the knee amputation, diabetes mellitus, and intellectual disabilities. Occupational therapy evaluation and the resident's care plan indicated that the resident required assistance from two staff members for bed mobility due to impaired mobility and balance. However, the care plan was revised to indicate total dependence on one staff member, despite the resident's decline in condition prior to the incident. On the day of the incident, a CNA provided incontinence care to the resident alone. The CNA rolled the resident onto his left side, away from where she was standing, while the bed was raised to her waist height. During care, the resident began coughing uncontrollably, which caused his upper body to shift and led to him falling off the bed and onto a floor mat. The CNA was unable to prevent the fall. The resident subsequently complained of pain in his right hip, and an x-ray revealed a nondisplaced right intertrochanteric hip fracture, which required surgical repair. Staff interviews confirmed that residents should not be rolled away from the caregiver, and that this resident should have been assisted by two staff members due to his condition. The facility's own policy and clinical resources emphasize the importance of proper positioning and adequate assistance to prevent accidents. The failure to follow these protocols and the care plan resulted in the resident sustaining a serious injury.