Failure to Provide Required Assistance During Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with chronic respiratory failure, hypoxia, and diabetes, who was moderately cognitively impaired and required extensive assistance for personal hygiene and bed mobility, was not provided the necessary care and services to prevent a fall from bed. According to the resident's care plan, two staff members were required to assist with bed mobility. However, during incontinence care, a nurse aide left the resident unattended on her side in bed to obtain washcloths, despite the resident's need for two-person assistance for bed mobility. As a result, the resident rolled out of bed and landed on her face, sustaining a raised bluish/purple area on the forehead and an acute fracture of the bony nasal septum, as confirmed by a CT scan. The bed was not in the lowest position at the time of the incident. The nurse aide involved confirmed leaving the resident alone, and the DON verified that the resident should not have been left unattended during care, which directly led to the fall.