Failure to Provide Adequate Supervision During Resident Repositioning Resulting in Fall and Fracture
Penalty
Summary
A resident with a history of cerebrovascular accident, right-sided hemiplegia, dysarthria, and right leg pain, who was care planned for impaired cognition, limited mobility, and high fall risk, was not safely repositioned during in-bed care. The resident required staff assistance for turning and bed mobility, including instruction cues and hand guidance. During a bed bath, a CNA was providing care alone when a basin of water was spilled, making the mattress wet and slippery. Despite the resident's inability to use her right side and the increased risk due to the wet surface, the CNA proceeded to turn the resident without additional assistance. As the resident was turned to her right side, she lost her balance and fell from the bed onto the floor. Following the fall, the resident complained of right knee pain, and an X-ray confirmed a mildly displaced fracture of the superior margin of the patella. The resident's care plan and staff interviews confirmed that two staff members were typically required for turning due to her physical limitations. The CNA involved acknowledged that the wet and slippery mattress contributed to the fall and that the resident's previous bed was smaller, which may have increased the risk. The facility's policy identified wet surfaces, cognitive impairment, and poor grip strength as fall risk factors, and the DON stated that a second person should have been called to assist after the water spill.