Failure to Provide Required Supervision During Incontinence Care Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of obesity, falls, hip fracture, muscle weakness, CVA, and dementia was not provided with adequate supervision during incontinence care. The resident's care plan and cardex both indicated a need for extensive assistance from two staff members for bed mobility and repositioning. Despite this, a CNA provided care alone and left the resident in a lateral position on the bed while leaving the room to retrieve additional towels. During this time, the resident slipped out of bed and sustained a distal femur fracture, as confirmed by clinical records and staff interviews. Facility documentation and staff statements revealed that the CNA had lowered the bed and left the resident unattended, contrary to the care plan requirements. The resident was found on the floor, complaining of knee pain, and was subsequently admitted to the hospital with a femur fracture. The Nursing Home Administrator and Director of Nursing confirmed that appropriate staff supervision was not provided during the incident, resulting in actual harm to the resident.