Failure to Provide Adequate Supervision and Assistance During Bedside Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement interventions consistent with a resident's needs to eliminate or reduce the risk of falling. The resident, who had diagnoses including hemiplegia, hemiparesis, and a left femur fracture, required total assistance with activities of daily living. The resident was assessed as high risk for falls and was dependent for bed mobility, requiring the assistance of two or more helpers. During a brief change, the resident was turned to the left side on a narrow bed without bedrails, and staff did not provide adequate support or supervision. The resident had nothing to hold on to and subsequently rolled off the bed, resulting in a fall and a fracture to the left leg. Interviews with staff revealed that the resident was sometimes allowed to hold onto a bedside table for support due to the lack of bedrails, but this was not consistently implemented. On the occasion of the fall, the CNA let go of the resident to retrieve wipes, leaving the resident unsupported, which led to the fall. The care plan identified the resident as high risk for falls, but individualized precautions were not effectively implemented during care. The DON stated that staff were expected to communicate concerns regarding fall risks, but was not aware of any issues related to this resident's care prior to the incident.