Resident Fall During Incontinence Care Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and limited mobility rolled out of bed and fell during incontinence care, resulting in significant injuries. The resident, who had diagnoses including coronary artery disease and dementia with agitation, required substantial assistance for bed mobility and positioning. At the time of the incident, the resident was being assisted by a nurse aide who asked her to roll over during care. The resident misunderstood the instruction and rolled in the opposite direction, falling off the bed onto the floor. The nurse aide reported that she was unable to prevent the fall because her hands were occupied holding a brief and pad, and the resident moved quickly. Following the fall, the resident was found on the floor with a bleeding scalp hematoma and a left leg that appeared shorter than the right. The nurse practitioner and nursing staff assessed the resident, who was subsequently sent to the emergency department. Medical evaluation revealed a non-displaced left hip fracture, a distal left femur fracture, and a scalp hematoma. The resident was treated with pain medication and a knee immobilizer, and her family opted against surgical intervention. The resident's care plan prior to the incident indicated she was a one-person assist for bed mobility, and she did not have bed rails on her bed. Interviews with staff indicated that the resident was considered able to roll herself and hold onto the bed during care, but confusion led to her rolling in the wrong direction. The nurse aide involved stated she did not anticipate the resident's action and could not intervene in time. The incident highlighted a failure to provide adequate supervision and ensure a safe environment during bed mobility and incontinence care for a resident at risk due to cognitive impairment and physical limitations.