Resident Fall Due to Inadequate Supervision During Bedside Care
Penalty
Summary
A deficiency occurred when a resident who was severely cognitively impaired and dependent on staff for all activities of daily living, including bed mobility, was not adequately supervised during personal care. The resident, who had diagnoses including dementia, dysphagia, and glaucoma, required extensive assistance and was unable to move independently. During the provision of incontinence care, a CNA positioned the resident on their side in bed and then turned away to retrieve a wet cloth from a table located diagonally behind her, leaving the resident unattended and out of her immediate reach. While the CNA's back was turned, the resident rolled off the bed and fell to the floor, sustaining a laceration to the back of the head. The bed was noted to be in its highest position at the time of the incident. The resident was found on their back, actively bleeding from the head wound. Immediate assistance was called, and the resident was transferred to the hospital emergency department for evaluation and treatment. Medical evaluation revealed that the resident required staples to close the head wound and was diagnosed with a left lateral epidural hematoma. Interviews with staff and family confirmed that the resident was completely dependent on staff for mobility and could not reposition themselves. The incident was attributed to the CNA turning away from the resident during care, resulting in a lack of adequate supervision and failure to ensure the resident's safety during a vulnerable moment.