Failure to Ensure Safe Positioning During Bedside Care Results in Resident Fall and Severe Fractures
Penalty
Summary
A deficiency occurred when a resident with a history of stroke and left-sided weakness rolled off a raised bed during incontinence care, resulting in multiple severe fractures. The resident, who required extensive assistance with transfers and was dependent on staff for bed mobility, was being cared for by a nurse aide who positioned her on her left side and instructed her to hold onto the upper side rail with her right hand. During the care, the resident stated she could not hold on any longer, released the rail, and rolled off the bed, landing on her knees and sustaining significant injuries. The care plan for the resident identified her as being at risk for falls due to her medical history, with interventions including the use of side rails during care and staff assistance for repositioning. However, during the incident, only the two top side rails were up, and the two bottom rails were down. The nurse aide was standing on the right side of the bed, performing care while the resident was facing away and holding the rail. The bed was raised to the aide's waist height, and the resident was positioned close to the edge of the bed. Despite the resident's known weakness and dependence, she was expected to maintain her position by holding the rail, which she was unable to do, leading to the fall. Interviews with staff and family members confirmed that the resident had limited mobility, with severe left-sided weakness, and that the facility was aware of her condition. The family expressed concerns that appropriate safety measures were not in place to prevent the resident from rolling out of bed during care. Documentation and staff statements indicated that no formal training or in-service was conducted for staff regarding resident safety or the use of side rails during care following the incident. The facility's investigation concluded the event was accidental, but the lack of adequate supervision and failure to ensure safe positioning during care directly contributed to the resident's fall and subsequent injuries.
Removal Plan
- Quality oversight meetings discussing unit needs including staffing, resources, education, training, and quality issues.
- Audit by the Director of Nursing to review all residents' mobility and transfer needs to ensure correct assistance levels on care plans.
- Update MDS assessments for all residents, including functional abilities and goals.
- Verbal and return demonstration education provided to licensed nursing staff and certified nursing assistants on proper positioning in bed, use of side rails, and adjusting bed height during care.
- Instruction on correct techniques for turning, boosting, and positioning residents.
- Staff required to review care plan and Kardex and follow specified staffing needs for transfers and mobility.
- Mandatory completion of education for all staff prior to their next scheduled shift, with removal from schedule if not completed.
- Responsibility for initiating baseline care plan during admission assessment shifted from MDS RN coordinator to admitting licensed nurse, including interventions for safe positioning during care.
- Update new hire orientation process for certified nursing assistants and licensed nurses to include education on proper positioning in bed, ergonomics, body mechanics, and safety precautions with lifting and moving residents.
- Education materials reviewed by licensed physical therapist and include written materials.
- Risk meetings involving interdisciplinary team members to discuss resident-specific changes in condition, falls, weight loss, infections, and mobility needs, with documentation in the medical record and on paper.
- Use of a risk meeting form by the notetaker.