Failure to Prevent Bed Fall Due to Improper Turning Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and had multiple comorbidities including cerebrovascular disease and severe cognitive impairment, sustained a fall from bed resulting in a head injury. The facility's fall prevention policy required individualized care planning and proper technique for turning and positioning residents in bed, including turning residents toward the caregiver and maintaining close proximity during movement. Despite these protocols, the resident was turned away from the Certified Nurse Aide (CNA) during in-bed care, and the CNA was not positioned on the side to which the resident was being turned. During the incident, the CNA turned the resident to the right side, away from themselves, while changing the resident's diaper and chux. The CNA then reached for clean linen placed at the foot of the bed, during which time the resident unexpectedly rolled and fell off the bed. The CNA attempted to prevent the fall but was unsuccessful. There were no side rails or grab bars on the bed, and the CNA did not call for additional assistance when turning the resident away from themselves, contrary to facility policy and supervisor instruction. Following the fall, the resident was found on the floor with a laceration and hematoma on the forehead, bruising on the hand, and an abrasion on the knee. The resident was alert and oriented, but due to the head injury, was transferred to the hospital where imaging revealed a subarachnoid hemorrhage and subdural hematoma. Interviews with staff confirmed that the CNA did not follow proper turning technique and did not seek help when required, directly contributing to the accident hazard and resulting injury.