Resident Fall and Injury During Improper Bed Movement in Peri-Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident's environment was free from accident hazards during peri-care. The resident, who had a history of falls, muscle wasting, lack of coordination, and severe cognitive impairment, was completely dependent on staff for all activities of daily living, including bed mobility and personal hygiene. The resident's care plan required a two-person assist for bed mobility and toileting, and staff were to be in-serviced on the required level of assistance and updates to the Kardex. During peri-care, the CNA encountered a situation where the resident had loose stool throughout the bed, including on the alternating air mattress, making the surface slick. The CNA cleaned one side of the resident and then attempted to move the bed away from the wall to access the other side. While the CNA was at the foot of the bed and moving it, the resident, who had been rolled to her right side, fell off the bed between the bed and the wall. The CNA confirmed that the bed was unlocked and that the slick mattress contributed to the fall. The resident was subsequently transferred to the hospital, where she was diagnosed with a right anterior superior iliac spine fracture, a forehead laceration, a right elbow soft tissue foreign body, and a right pulmonary nodule. Interviews with staff revealed that peri-care assistance was not documented on the Kardex prior to the incident, and that staff had been trained not to move beds during peri-care, but the CNA did not follow this protocol. The CNA stated she had previously been told the resident was a one-person assist for peri-care, but could not recall the details. Other CNAs and the Director of Nursing confirmed that beds should not be moved during peri-care and that if a bed needed to be moved, it should be done prior to starting care and with assistance. The facility's policy on perineal care emphasized reviewing the care plan and ensuring resident safety, but these steps were not followed, resulting in the resident's fall and injuries.