Failure to Follow Care Plan for Bed Mobility Results in Fatal Fall
Penalty
Summary
A cognitively impaired resident with a tracheostomy, who was dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, fell from an elevated bed and sustained a fatal head injury. The resident's care plan and medical record clearly indicated the need for two-person assistance with bed mobility and transfers, as well as the use of a mechanical lift. The resident was also noted to be unable to follow commands, was nonverbal, and was totally dependent on staff for repositioning. On the night of the incident, a certified nursing assistant (CNA) entered the resident's room alone to provide care and prepare for repositioning. Despite the care plan's requirement for two-person assistance, the CNA proceeded without additional help. While the CNA was gathering supplies and standing behind the resident, the resident rolled off the bed and fell face down onto the floor, resulting in a laceration to the forehead. The CNA did not attempt to reposition the resident or provide hands-on care prior to the fall, and the bed was elevated to the CNA's hip level at the time of the incident. The resident's ventilator tubing became disconnected during the fall, and emergency assistance was called. Interviews with facility staff, including the DON, RN, and Nurse Practitioner, confirmed that the resident was completely dependent on staff for movement and could not reposition herself. The CNA failed to follow the care plan instructions, which directly contributed to the resident's fall and subsequent death. The facility was cited for failing to provide an environment free from accident hazards and for not ensuring adequate supervision and assistance as required by the resident's care plan.