Failure to Provide Adequate Supervision and Safe Assistance During Personal Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and a high risk for falls was not safely assisted during personal care, resulting in a fall with significant injuries. The resident required extensive assistance from two staff members for bed mobility, toileting, and transfers, as documented in the care plan. However, during incontinence care, only one CNA was present and attempted to pull a draw sheet from under the resident, which caused the resident to roll over the mattress guard and fall to the floor. The resident sustained traumatic injuries to the face and head and was subsequently transported to the hospital. The investigation revealed that the CNA was unaware of the autofirm function on the alternating pressure mattress, which could have provided a firmer surface for care and potentially prevented the fall. The CNA reported not being trained on this feature prior to the incident. The facility's documentation showed that the care plan required two-person assistance, but only one staff member was present at the time of the fall. Additionally, the mattress in use had side bolsters, which may have contributed to the difficulty in safely repositioning the resident. A review of the facility's fall investigation process found it to be incomplete, as only a single statement from the involved CNA was provided and there was no evidence of a thorough root cause analysis. The IDT follow-up note did not identify the root cause of the fall, and the facility's fall and accident management policy was not fully implemented. Observations and interviews confirmed that the resident was dependent on staff for all care and unable to protect herself from falls, highlighting the lack of adequate supervision and hazard mitigation during personal care.