Failure to Provide Adequate Supervision and Assistance During Resident Repositioning
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and assistance to prevent accidents for a resident with quadriplegia. The resident, who was alert and oriented but completely dependent on staff for activities of daily living (ADLs), required two-person assistance for bed mobility and personal care. Despite this, a CNA attempted to reposition the resident alone and left the resident unattended on their side while leaving the room to obtain supplies. During the period the resident was left unattended, the resident experienced a spasm, causing their legs to move and resulting in a fall from the bed. The resident landed on the floor, hitting their head on the bedside table and sustaining a contusion to the back of the head. The incident was unwitnessed, and the resident reported pain in the neck and back of the head after the fall. The CNA's actions were inconsistent with the resident's care plan, which specified the need for two-person assistance for all ADL care, including turning and personal hygiene. Multiple staff interviews confirmed that the resident required two-person assistance and that staff were expected to gather all necessary supplies before entering the room to provide care. The CNA involved did not follow these protocols, resulting in the resident being left in a vulnerable position and subsequently falling. The incident was reported to nursing staff, and the resident was assessed and sent to the hospital for evaluation.