Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during incontinence care for a resident with multiple medical conditions, including vascular dementia, chronic kidney disease, and a history of falls. The resident was assessed as being at high risk for falls and was dependent on staff for activities of daily living, mobility, and transfers. During the incident, the CNA rolled the resident away from themselves while the bed was positioned next to the wall, contrary to facility policy, which states that residents should be rolled toward the caregiver when only one staff member is assisting. As a result, the resident rolled off the bed and onto the floor, landing in the space between the bed and the wall. The resident did not sustain an injury from the fall. Interviews with multiple CNAs and nursing leadership confirmed that the expectation is to roll residents toward the caregiver during care when only one staff member is present. The CNA involved in the incident did not follow this protocol, and there was uncertainty about whether the bed was properly positioned or if the brakes were locked at the time of the incident. The facility's policy and staff interviews consistently indicated that the correct procedure was not followed, leading to the resident's fall.