Improper Repositioning and Inadequate Supervision of Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) improperly repositioned a dependent male resident with multiple complex medical conditions, including acute and chronic respiratory failure, end stage renal disease, a tracheostomy, and a history of being fully dependent for activities of daily living. The resident was observed on video lying sideways in bed with his head hanging off the edge. CNA A entered the room and, without assistance, pulled the resident by his left arm to reposition him toward the center of the bed. Another CNA entered the room during the incident but did not intervene in the repositioning process. Interviews with staff and the resident's family member confirmed that the resident was unable to move himself and was at risk of falling from the bed. The family member reported witnessing the incident via a camera in the resident's room and described the repositioning as rough and inappropriate, though no bruising was observed. Both CNAs involved acknowledged that the repositioning technique used was not appropriate and did not follow proper procedures, with CNA A stating she acted out of fear that the resident would fall. CNA A also admitted she had not received recent training on proper repositioning techniques. A review of the facility's policy on turning and repositioning indicated that such care should be individualized, planned, and performed according to established procedures, with documentation required every shift. The incident demonstrated a failure to provide adequate supervision and to follow proper repositioning protocols, as the resident was handled in a manner inconsistent with facility policy and best practices for dependent residents.