Failure to Prevent Avoidable Fall Resulting in Resident Injury and Death
Penalty
Summary
A resident with quadriplegia, dementia, and a history of physical injury was admitted to the facility and assessed as being at high risk for falls, with severe cognitive impairment and total dependence on staff for mobility and toileting. The care plan specified that the resident's bed should be kept in a low position and that two or more staff were required for toileting hygiene and repositioning. Despite these interventions, the resident was left alone in a high bed position with both side rails down while a CNA left the room to obtain additional supplies during incontinent care. During this period of unsupervised time, the resident rolled from the bed and fell to the floor, sustaining multiple injuries including a head injury, abrasions, and skin tears. The CNA reported leaving the resident on their side and did not return the resident to a supine position before leaving. The resident's low air loss mattress, which was ordered to prevent skin breakdown, had been removed at the time of the incident. The facility's documentation and staff interviews confirmed that the CNA had not received specific training on the use of low air loss mattresses or fall safety, and competency validation for peri-care was not documented in the employee file. The facility's policies required a hazard-free environment and adequate supervision to prevent accidents, but these were not followed in this case. The resident's fall resulted in a traumatic brain injury, hospitalization, and subsequent death. The facility's investigation identified the resident's positioning and the absence of the low air loss mattress as contributing factors to the fall.