Failure to Ensure Resident Safety During In-Bed Care and Inaccurate Fall Risk Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety of a resident during in-bed care. The resident, who had severe cognitive impairment, was dependent on staff for all self-care and mobility activities, and had impairments in one upper and both lower extremities. During routine in-bed care, a CNA rolled the resident to the side of the bed without the required assistance of a second staff member, resulting in the resident falling from the bed onto a floor mat. The fall led to comminuted fractures of the right tibia and fibula, necessitating hospital transfer. The facility also failed to accurately complete the resident's fall risk assessment. Despite a documented unwitnessed fall within the previous 90 days, the assessment did not reflect this incident, resulting in an inaccurate fall risk score. Facility policy required that nursing staff review the resident's record for a history of falls, especially within the last 90 days, but this was not properly followed. Additionally, the facility did not implement the resident's care plan intervention to ensure proper positioning in bed. The care plan, which identified the resident as being at risk for falls due to multiple factors including confusion, gait and balance problems, and muscle atrophy, included an intervention to ensure the resident was properly positioned in bed. Staff failed to follow this intervention during the in-bed care that led to the fall and injury.