Failure to Provide Adequate Supervision During ADL Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment was free from accident hazards and that a resident received adequate supervision and assistance devices to prevent accidents. The incident involved a male resident with a history of traumatic brain injury, craniectomy with no bone flap on the left side of his skull, tracheostomy, and a persistent vegetative state. The resident was totally dependent on at least two staff members for activities of daily living (ADL) care, including bed mobility and bathing, and was assessed as being at moderate risk for falls. On the day of the incident, two CNAs were providing a bed bath to the resident. One CNA left the bedside to retrieve clean linens, leaving the other CNA alone with the resident. During this time, the remaining CNA rolled the resident to his side, at which point the resident began to slide off the bed, with his forehead pressed against the wall. The second CNA returned and assisted the resident to the floor. The resident was found with a reddened area on the right side of his forehead. There was no helmet in use, and there were no physician orders for a helmet at the time, despite the family’s request for helmet use during repositioning due to the resident’s craniectomy. Interviews with staff confirmed that the resident required two-person assistance for all ADL care and that both staff members should have remained at the bedside during care. The failure to maintain two-person supervision during ADL care directly led to the resident’s fall and subsequent injury, which resulted in rehospitalization. The facility’s policy required staff to remain with residents during ADL care and to provide the necessary level of assistance based on the resident’s needs.