Injury During Incontinent Care Due to Inadequate Environmental Safety and Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, Alzheimer's disease, and muscle weakness, did not receive adequate supervision and environmental safety during a routine incontinent care procedure. The resident required a two-person assist for activities of daily living and was dependent for toileting hygiene and bed mobility. During the care event, two CNAs were turning the resident when she made an unpredictable movement, resulting in her head striking a bedside table that was positioned close to the bed. The incident led to a laceration above the resident's right eyebrow and significant bruising around the right eye. Documentation and staff interviews confirmed that the resident did not fall from the bed, but the proximity of the bedside table contributed to the injury when the resident moved unexpectedly during the turn. The injury was immediately reported, and assessments were conducted, including a neuro check and imaging, which showed no fractures but confirmed soft tissue injury. The care plan for the resident indicated the need for substantial assistance and proper alignment during repositioning, but the environmental setup—specifically the placement of the bedside table—was not adequately managed to prevent accidental injury. Staff statements and medical records consistently described the sequence of events leading to the resident's injury, highlighting a lapse in ensuring a hazard-free environment and sufficient supervision during care for a resident with significant physical and cognitive limitations.