Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including diabetes, cardiomyopathy, congestive heart failure, and morbid obesity, was not provided adequate supervision during care. The resident, who required partial to moderate assistance with bed mobility and was care planned for one-person assist, rolled out of bed while being changed by a CNA after starting to cough. This resulted in a significant laceration to the right lower leg, exposing the tendon and requiring hospital treatment and sutures. The incident took place while the resident was on a bariatric air mattress, and the care plan at the time specified monitoring the resident's position in bed every two hours. The facility's policies require staff to provide necessary goods and services to prevent physical harm and to treat residents with dignity and respect. However, the review of clinical records and staff interviews confirmed that the supervision provided was not adequate to prevent the fall and subsequent injury. The resident's care plan and assistance level were only updated after the incident, indicating that the supervision and assistance provided at the time of the event did not meet the resident's needs, resulting in a preventable accident and injury.