Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Parkinson's disease, impaired mobility, and a history of being combative with care, fell from their bed and sustained a laceration to the left eyebrow. The resident was completely dependent on staff for all activities of daily living, including bed mobility and transfers, and required the assistance of two staff members for these tasks. On the day of the incident, a certified nurse aide was providing care alone and turned away from the resident to retrieve a mechanical lift pad, during which time the resident fell from the bed to the floor. The resident's care plan and assessment documentation indicated a need for two-person assistance for bed mobility and transfers due to the resident's inability to move independently and their tendency to be combative, including kicking, hitting, and reaching for objects. Despite these documented needs, the aide performed care and repositioning without a second staff member present. The resident was positioned in bed with their body against the wall, and the bed was in a low position, but the aide left the resident unattended while turning to get equipment, resulting in the fall. Interviews with staff confirmed that the resident was known to be completely dependent and often combative, requiring two-person assistance for safe care. The environment at the time of the incident was otherwise free of hazards, with appropriate fall precautions in place, but the lack of adequate supervision and failure to follow the resident's care requirements directly led to the accident and injury.