Failure to Provide Adequate Supervision and Safe Repositioning During Pericare
Penalty
Summary
Facility nursing staff failed to provide adequate supervision and utilize proper turning techniques during pericare for a fully dependent, bedridden resident with severe cognitive impairment and multiple comorbidities, including Parkinson's disease, hypothyroidism, hyperlipidemia, depression, dysphagia, coronary artery disease, and a pacemaker. The resident required total assistance for all activities of daily living, including toileting and repositioning, and was assessed as dependent, meaning all effort for these activities was to be provided by staff. Despite this, a certified nursing assistant (CNA) attempted to change the resident's brief without using a draw sheet or proper positioning technique, and did not request assistance from another staff member, even though staffing levels were sufficient to allow for a second helper. During the incident, the CNA turned the resident on her side, allowing her feet to dangle off the bed, and then turned away to dispose of a soiled brief. At this point, the resident fell from the bed to the floor, sustaining a scalp laceration, traumatic brain injury with intracranial hemorrhage, left rib fracture, left pneumothorax, and a manubrial fracture, requiring urgent transfer to an acute care hospital and admission to the ICU. The CNA did not pull the resident close or use a draw sheet as required by facility competency and training, and instead relied on verbal instructions to the resident, who was unable to assist or follow commands due to her cognitive and physical limitations. Interviews and record reviews confirmed that the CNA did not follow established protocols for safe repositioning, and that the resident's care plan and assessments clearly indicated the need for full assistance. The facility's own policies and competency checklists required the use of draw sheets or proper manual techniques for moving dependent residents, and staff were trained to seek assistance when needed. The failure to implement these interventions and provide adequate supervision directly resulted in the resident's avoidable fall and serious injuries.