Failure to Provide Adequate Supervision During Incontinent Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision to a resident during incontinent care, resulting in the resident falling from the bed. The resident, an elderly male with diagnoses including unspecified dementia, syncope, anxiety disorder, atrial fibrillation, and adult failure to thrive, was assessed as high risk for falls and required one-person assistance for toileting and bed mobility. The care plan specified the use of mobility bars to aid in repositioning, and the resident was dependent for toileting hygiene and bed mobility due to severe cognitive impairment. During the incident, the CNA was providing incontinent care with the resident positioned on his side. The CNA was momentarily distracted when another CNA entered the room to request assistance with another resident. The first CNA turned away briefly to respond, and in that moment, the resident rolled off the bed and fell to the floor. The CNA was standing next to the bed but was not holding onto the resident at the time of the fall. The fall was witnessed, and the CNA immediately called for nursing assistance. Following the fall, the resident sustained multiple injuries, including a traumatic intracranial hemorrhage, lacerations, and abrasions. The resident was sent to the hospital for evaluation and treatment, but the family opted for palliative care, and the resident later expired. Interviews with staff confirmed that the CNA was not maintaining direct supervision or physical support of the resident during care, despite the resident's high fall risk and dependency. The failure to provide adequate supervision and assistance during care directly led to the resident's fall and subsequent injuries.