Resident Fall During Incontinence Care Due to Improper Positioning
Penalty
Summary
Facility staff failed to safely and properly position a resident in bed during incontinence care, resulting in a fall. The resident involved had severe cognitive impairment, dementia, depression, cerebrovascular disease, and was dependent on staff for all activities of daily living. During incontinence care, a CNA rolled the resident onto her right side, away from herself, and while reaching for a clean brief at the end of the bed, the resident rolled out of bed and onto the floor. The bed was raised at the time, and the resident was left unsupported on the side away from the caregiver. Medical record review and staff interviews confirmed that the resident was not positioned or supervised in accordance with safe care practices during the incident. The resident sustained bruises to her left arm and forearm as a result of the fall, though x-rays showed no fractures. Staff interviews further confirmed that residents should not be rolled away from the caregiver during care, as this increases the risk of falling out of bed.