Failure to Prevent Accident During Bed Bath Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide care consistent with a resident's needs and care plan during a bed bath, resulting in an accident. The resident involved had multiple diagnoses, including low back pain, chronic congestive heart failure, a prior left femur fracture, generalized weakness, and was on hospice care. The care plan required two staff to assist with bed mobility and directed the use of a draw sheet to prevent shearing and sliding. During the incident, the resident was left on a bare air mattress without a draw sheet after the soiled linen was removed, and one staff member left the room to retrieve a clean draw sheet, leaving the other staff member alone with the resident. While repositioning the resident for care, staff did not use a draw sheet and applied excessive force, causing the resident to slide off the bed and fall to the floor. The bed brakes were not engaged on both sides, and the resident was undressed at the time of the fall. The staff involved did not review the care plan prior to providing care, and one of the staff members was unfamiliar with the resident and the hallway. There were inconsistencies in staff accounts regarding their presence and actions during the incident, and it was unclear whether proper procedures were followed. As a result of the fall, the resident sustained a comminuted and displaced fracture of the left femur, which required surgical intervention. The incident was witnessed by other staff who responded after hearing a noise and finding the resident on the floor. The facility's policy required protection from harm and adherence to care plans, but these were not followed during the incident, directly leading to the resident's injury.