Failure to Provide Required Bed Safety Measures During Resident Care
Penalty
Summary
A deficiency occurred when a resident who required maximum assistance with bed mobility was not safely turned during care, resulting in the resident rolling out of bed and sustaining a laceration to the forehead. The resident, who had severe cognitive impairment, functional limitations in both lower extremities, and a history of traumatic brain injury, was being cared for by a CNA alone. During a brief change, the resident was turned toward the left side, away from the CNA, and subsequently swung a leg over the bed edge, rolling out and falling face-first onto the floor. The resident was found lying between the bed and the wall, bleeding from the head, and was sent to the emergency room where 12 stitches were required for the forehead laceration. The care plan for this resident specified the use of two quarter side rails to assist with turning and repositioning in bed, and instructed staff to have the resident grab onto the side rail to aid in mobility. However, at the time of the incident, the bed did not have any side rails or other devices in place to prevent the resident from rolling out of bed. The CNA reported that the air mattress was flat and there were no side bolsters or bedrails attached to the bedframe. The CNA also stated that, because the resident was undressed during care, there was no way to safely grab and prevent the fall once the resident began to roll. Interviews with facility staff, including the Director of Nursing and the Nurse Practitioner, confirmed that the plan of care required the use of two quarter side rails for safety during bed mobility. Both acknowledged that the absence of these side rails at the time of care likely contributed to the resident's ability to roll out of bed and sustain injury. The incident was not attributed to a suicidal attempt by facility staff, despite a note in the hospital record, and the resident was described as cognitively impaired and not a reliable historian.