F0689

D

Failure to follow care plan and ensure competent assistance during bedpan use leading to fall with injury

Jackson, Michigan Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during care, resulting in a fall from bed with injury. The resident, identified as R7, experienced an incident in which she fell or rolled out of bed while being assisted with a bedpan, landing on her face, splitting her lip, and breaking a tooth. The incident summary notes that the bed was in a low position and that the resident stated something slipped and she fell. Emergency room evaluation confirmed no fractures but documented the need for sutures to the upper lip and a broken front tooth.

Prior to the incident, facility records contained inconsistent and incomplete assessments and directions regarding the resident’s functional status and required level of assistance. The care plan and Kardex documented that the resident required assistance from two staff for bed mobility (turning and repositioning in bed) and for transfers with a hoyer/mechanical lift, and that she required assistance from one staff to use the bedpan. However, the MDS functional status section showed multiple mobility and transfer items as “not assessed” as of the day before the incident, including chair/bed transfers, lying to sitting, sit to lying, toilet transfer, toileting, and transferring. A transfer report also documented that the resident only needed assistance with toileting and transfers and was not dependent on care, which conflicted with the care plan and Kardex indicating two-person assistance for certain tasks.

On the night of the incident, the CNA assigned to the resident (CNA K) assisted her with the bedpan without a second staff member present. In an interview typed by the Nursing Home Administrator (NHA), the resident reported that she wanted to get up, that the CNA was helping her off the bedpan, and that she felt herself sliding before she rolled out of bed; she stated the CNA was not being mean and that she believed the CNA had not hooked her up correctly. In a separate typed interview, CNA K stated that the resident wanted to use the bedpan, that she placed the resident on it and checked on her multiple times, and that when she attempted to remove the bedpan, the resident began yelling and then threw herself on the floor. CNA K acknowledged she had not reviewed the Kardex that night and did not know the resident was a two-person assist, and she did not ask anyone for assistance. The facility’s own incident summary later stated that the allegations were substantiated due to the CNA not following the plan of care.

Additional record review revealed broader deficiencies related to staff preparation and documentation that contributed to the unsafe situation. The personnel file for CNA K, who had been hired approximately two months before the incident, lacked a completed new hire checklist, reference checks, I-9, background checks, eligibility letter, sex offender registry check, certification verification, pre-hire drug screen and physical, TB test, driver’s license verification, general orientation checklist, CNA-specific competency evaluations, and verification of orientation completion before working on the units. There was also no evidence that CNA K’s competency in performing two-person transfers or other required CNA skills had been assessed. Interviews with staff on first and third shifts indicated they were aware the resident was a two-person assist for care, and nursing staff reported that the resident had been exhibiting behaviors and yelling at staff during care in the evenings. Despite this, there was no documented investigation into the competencies of CNAs providing two-person transfers on the day or unit of the incident, and no hands-on demonstrations or return demonstrations were recorded for staff performing two-person transfers.