Failure to Provide Adequate Supervision During Incontinent Care Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including dementia, hemiplegia, hemiparesis, and a high risk for falls, was not adequately supervised during incontinent care. The resident was dependent on staff for bed mobility and required total assistance for activities of daily living. The care plan and electronic health record indicated the resident was a one-person assist for bed mobility, and staff were trained accordingly. During the incident, a CNA attempted to provide incontinent care by turning the resident onto her weak side without first pulling her closer, resulting in the resident rolling off the bed. The CNA reported that she was unable to prevent the resident from falling despite holding onto her leg and arm as the resident rolled off the bed. The resident sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction, as well as a non-displaced fracture of the right distal femoral shaft. The incident report and nurse notes confirmed that the resident complained of severe pain and had visible injuries following the fall. The resident was transported to the hospital for evaluation and treatment of her injuries. Interviews with staff and review of records revealed that the resident's bed was set at its highest position and she was on an air mattress, which may have contributed to the fall. The CNA involved stated she did not pull the resident toward her before turning, citing lack of space, and believed it would not have made a difference. The DON confirmed that staff are expected to pull residents toward them before rolling and acknowledged that failure to do so could result in falls and injuries. The care plan at the time of the incident did not specify a need for two-person assistance for bed mobility, and other CNAs reported no difficulty providing care with one-person assistance.