Resident Fall During Incontinence Care Due to Improper Supervision and Positioning
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had diagnoses including a left lower leg wound, anxiety disorder, and arthritis, rolled off her bed while receiving incontinence care from a nurse aide. The incident happened as the nurse aide was preparing to assist the resident with turning, but had not yet started the usual countdown or physically assisted the resident. The resident, while holding the transfer bar, moved her legs off the bed and subsequently rolled off, landing on the floor and hitting her face against the wall. The nurse aide was positioned on the opposite side of the bed at the time and had intended to move to the other side before turning the resident. Following the fall, the resident complained of significant knee pain and was unable to be moved back to bed by staff due to her discomfort. Emergency Medical Services were called, and the resident was transported to the hospital for evaluation. Medical assessments, including imaging and laboratory tests, were performed and found to be negative for acute injury. The resident reported pain in her head, back, and knees, and subsequently refused to return to the facility, remaining in the hospital awaiting alternate placement. Interviews with staff and the resident revealed inconsistencies in the sequence of events, but it was confirmed that the nurse aide did not follow proper procedure by ensuring the resident was turned towards her and by not being on the correct side of the bed during care. The Director of Nursing and the facility administrator both acknowledged that the nurse aide should have positioned herself appropriately and guided the resident through the care process to prevent such an accident.