Failure to Provide Required Supervision and Safe Positioning During Resident Repositioning
Penalty
Summary
A deficiency occurred when a resident, a 37-year-old male with a history of unspecified convulsions, schizophrenia, weakness, and traumatic brain injury, was not provided the required level of care and supervision to prevent accidents. The resident was care planned as a high fall risk and required two staff members for all bed mobility and repositioning. Despite this, a CNA attempted to reposition the resident alone, resulting in the resident being left in a diagonal position on the bed with both legs hanging off the side up to the knees, the bed in a raised position, and the call light out of reach. Video evidence showed the CNA making several unsuccessful attempts to reposition the resident, who exhibited muscle rigidity and resistance to movement. The CNA then left the resident unattended in this unsafe position, stating, "I can't be doing this all day," and exited the room. The resident remained unsupervised with the bed elevated and his legs off the bed until the CNA returned with another staff member. The care plan and Kardex clearly indicated the need for two-person assistance for repositioning, which was not followed. Interviews with facility leadership, including the DON, Administrator, and Corporate Administrator, confirmed that the CNA should not have attempted to reposition the resident alone or left the resident in an unsafe position. The staff acknowledged that the resident was at high risk for falls and that the actions taken were not in accordance with the resident's care plan or facility policy. The deficiency was identified as past noncompliance, and the incident was self-reported by the facility after review of the video evidence.