Failure to Provide Safe Repositioning Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide safe turning and repositioning care for a resident with significant physical impairments and a history of falls. The resident, who was cognitively intact but had one-sided weakness and required substantial assistance with activities of daily living, was at high risk for falls due to conditions including Parkinson's disease and a previous hip dislocation. After receiving a shower, the resident was returned to bed, which was equipped with a low air mattress. Only one certified nursing assistant (CNA) was present, despite facility protocol requiring two staff members for such care. The CNA attempted to turn the resident alone to apply lotion, without placing a blanket underneath as expected for residents on low air mattresses, and the resident subsequently slid off the bed and fell to the floor. Interviews and documentation confirmed that the resident was wet from the shower, making the surface slippery, and that the CNA was aware of the requirement for a second staff member but proceeded alone due to being busy. The Director of Nursing acknowledged that staff are expected to use a blanket to prevent slipping on air mattresses, which was not done in this instance. The facility's fall policy emphasizes the need to recognize and address high fall risk, but these procedures were not followed, resulting in the resident sustaining an abrasion and requiring hospital evaluation.