Resident Fall and Injury Due to Improper Repositioning by CNA
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) assisted a resident in a hurried manner, resulting in the resident falling from a wheelchair. The resident, who had diagnoses including contracture of muscle in the lower leg, dementia, and a recent intracapsular fracture of the right femur, was dependent on staff for mobility and required the use of a mechanical lift for all transfers. Despite these needs, the CNA attempted to reposition the resident in a Broda chair by pushing on a stuck lever, which caused the resident to tip forward and fall to the floor, sustaining a laceration to the mouth and a hairline fracture below the right knee. The facility's policies required staff to ask permission before repositioning residents and to ensure resident safety, dignity, and comfort during lifting and movement. Staff were also expected to be observed for competency in using equipment and to adhere to safe lifting techniques. However, the CNA involved had not completed documented skills competency reviews or new employee training, and there was no evidence of training or skills checks in the personnel file. Interviews with staff and family members confirmed that the CNA did not announce themselves or explain the repositioning process to the resident, contrary to facility policy and standard practice. Prior to the incident, concerns had been raised about the CNA moving too quickly with residents, and the CNA had been re-educated on the need to slow down and be gentle. Despite this, the CNA proceeded to reposition the resident without proper communication or technique, leading to the fall and injury. Multiple staff and family interviews corroborated that the CNA's actions were rushed and not in accordance with established procedures for resident safety.