Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a fall that resulted in actual harm to a resident. The resident, who had a history of paraplegia, hemiplegia following a CVA, and other significant medical conditions, required substantial or maximal assistance for bed mobility and an assist of two for activities of daily living (ADLs). During a bed change, two CNAs were present and the resident was rolled onto his side, but was unable to stop rolling and fell from the bed, sustaining a large laceration on the forehead that required sutures. The incident report and staff statements indicated that while one CNA turned to grab a washcloth, the resident slipped out of bed and staff were unable to prevent the fall due to the resident's weight and loss of balance. The resident's care plan and facility policies required an assist of two for bed mobility and ADLs, and staff were expected to follow these instructions as documented in the Kardex and care orders. Despite these requirements, the fall occurred during routine care, and the resident suffered a significant injury. Staff interviews confirmed knowledge of the care requirements and the use of the Kardex for safety measures, but the incident still resulted in harm. Clinical documentation showed that the resident was alert and oriented at the time of the incident, and after the fall, was assessed and transferred to the hospital for treatment. The facility's failure to ensure adequate supervision and safe handling during bed mobility directly led to the resident's fall and injury. The deficiency was confirmed by review of facility policies, clinical records, incident reports, and staff interviews.