Failure to Provide Adequate Assistance and Safe Equipment During Incontinence Care Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide adequate assistance during incontinence care for a resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including dementia, schizoaffective disorder, Alzheimer's disease, cerebral vascular disease, and tardive dyskinesia, required substantial maximal assistance for toileting, personal hygiene, transfers, and lower body dressing. During care, a CNA provided assistance alone and rolled the resident away from herself toward the window, instructing the resident to hold onto the side rail. While the resident was being repositioned, she began to shake the side rail, which subsequently gave way and detached from the bed. This resulted in the resident falling from the bed onto the floor, landing face down. The resident sustained a laceration to the forehead, which required cleaning and suturing at the hospital. The incident was witnessed by the CNA, who immediately sought help from nursing staff. The facility's investigation identified equipment failure with the bed's side rail, as the pins attaching the rail were loose. The CNA involved reported being educated to check side rails before use and to seek assistance for care involving residents requiring substantial help. The DON described the expected procedure for providing care to such residents, which included ensuring side rails were secure, proper positioning, and having appropriate staff assistance, but these steps were not followed during the incident.