Failure to Provide Adequate Supervision During Care Resulting in Resident Fracture
Penalty
Summary
A resident with a history of cerebral infarction and left-sided hemiplegia required total assistance from one staff member for bed mobility and care, as documented in the care plan and Minimum Data Set. During care, a CNA rolled the resident onto their side to change them, removed the brief, and placed it on the floor. While the CNA was momentarily distracted, the resident rolled out of bed and fell to the floor. The resident was found lying on their left arm in a semi-prone position on the right side of the bed, with visible injuries including a bump on the forehead, a bruise on the left arm, and complaints of right ankle pain. Subsequent assessment and hospital evaluation revealed the resident sustained a nondisplaced fracture of the right ankle, with X-rays indicating possible fractures of the distal fibula and tibia, as well as severe diffuse osteopenia. Facility documentation and staff interviews confirmed that the resident did not receive adequate supervision during care, which resulted in actual harm. The Director of Nursing acknowledged that staff failed to provide the necessary supervision, leading to the resident's fall and injury.