Resident Fall During Incontinence Care Due to Inadequate Supervision and Bed Size
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and required a two-person physical assist for bed mobility, experienced a fall during incontinence care. The resident, who weighed over 300 pounds and had left-sided weakness from a previous stroke, was being cared for by a CNA and an LPN. During the care, the LPN left the room to obtain cream for the resident's excoriated skin, leaving the CNA alone with the resident. While the CNA was positioned on one side of the bed, the resident rolled over and fell off the bed onto the floor. The bed in use was a collapsible bariatric bed extended to 42 inches, but staff reported that the bed was still too small for the resident to fit comfortably. The resident was partially clothed and incontinent at the time of the fall. The CNA was unable to reach the other side of the bed to assist the resident as she rolled off. The fall was witnessed, and emergency services were called to assist in transferring the resident from the floor to a stretcher. As a result of the fall, the resident sustained multiple skin tears and was hospitalized with an eight-millimeter right frontal convexity subdural hematoma, as confirmed by a CT scan. The incident occurred while the resident was being prepared for dialysis, and the lack of adequate supervision and appropriate bed size contributed to the accident. The facility's documentation and interviews confirmed that staff did not remain with the resident throughout care and that the bed may not have been suitable for the resident's size.