Failure to Provide Adequate Supervision and Safe Repositioning Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to follow established facility policies and procedures regarding the safe repositioning of a resident who was dependent on a ventilator and required a two-person assist for bed mobility. The CNA repositioned the resident alone, without assistance, and placed the resident on top of the ventilator circuit tubing. This action was contrary to the facility's policy, which specifically required two staff members to assist with turning or moving residents in bed, especially those with significant functional limitations. The resident involved had a history of cerebrovascular accident, diabetes mellitus, and was dependent on a ventilator, residing in the facility's sub-acute unit. The resident was documented as having severe cognitive impairment and functional limitations in both upper and lower extremities, making her totally dependent on staff for all aspects of self-care and bed mobility. The care plan and assessment tools clearly indicated the need for a two-person assist for any repositioning or bed mobility tasks. As a result of the CNA's actions, the resident sustained a skin tear with minimal bleeding to her left upper lip, which was discovered by a nurse during routine wound care. Interviews with staff and review of records confirmed that the CNA did not seek assistance as required, and the resident was found lying on the ventilator circuit, which contributed to the injury. Facility policies emphasized the importance of resident safety, supervision, and targeted interventions to reduce individual risks, but these were not followed in this instance.