Failure to Provide Safe Incontinence Care to Combative Resident Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care. The resident involved had multiple significant diagnoses, including Alzheimer’s disease, Parkinson’s disease, history of transient ischemic attack, chronic pain syndrome, essential hypertension, major depressive disorder, orthostatic hypotension, and non‑traumatic brain dysfunction. A quarterly MDS showed he had severely impaired cognitive skills, no recall ability, dependence on staff for all care, bowel incontinence, and an indwelling urinary catheter. He had a history of falls with minor injury and was receiving hospice care, as well as antibiotic, opioid, and antipsychotic medications. The resident’s care plan identified him as at risk for falls related to use of a mechanical lift and documented a history of recurrent falls. A separate behavior care plan identified him as at risk for behavior problems related to dementia and refusal of care or medications, with a history of anxiety, refusal of care, choking a staff member, restlessness, wandering, suicidal ideation, and combative behavior. Specific documented behaviors in the days prior to the incident included swinging his hands with balled fists, grabbing and squeezing staff hands, being combative during incontinence care, grabbing and digging his nails into staff skin, clenching arms and legs to prevent bathing, throwing offered items such as stuffed animals or washcloths to the floor, and hitting a nurse during a pain patch change. Interventions included assisting with self‑care needs, determining triggers for behaviors, intervening to ensure safety, monitoring hand placement during care, and gently holding the resident’s hands during care as able. On the day of the incident, a nurse aide decided to provide incontinence care around suppertime after the resident had a bowel movement, before meal trays arrived. During the first brief change, the resident remained calm while the aide talked to him. After the brief was applied, the resident had a second bowel movement, and the aide began incontinence care again. At that point, the resident started to hit and pinch the aide, who then stopped care and used her radio to summon a second staff member. She reported that all other staff were occupied providing care in other rooms. While waiting, she was able to calm the resident and, without a second staff member present, resumed incontinence care. The resident, who was facing away from her while she was wiping his rectal area, grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a nearby dresser. The aide stated it was normal for him to hold onto the bed frame during care and believed it was a comfort measure. She also stated that the resident was not care planned for a two‑person assist during ADL care and acknowledged that the accident might have been avoided if she had waited for assistance. When the nurse responded to the aide’s call after the fall, the resident was found lying on the floor between the bed and the dresser, bleeding from a forehead laceration. The nurse documented that the aide reported the resident had pulled himself off the bed while she was cleansing him after a large soft bowel movement. The resident’s vital signs were recorded, and he was sent to the emergency department, where he was treated for a soft tissue skin tear to the forehead that required cleansing and steri‑strips. Imaging, including a head CT and pelvic x‑ray, showed no acute injury. Interviews with the nurse, DON, and Administrator confirmed that the resident was known to become combative during ADL care, that the aide had attempted to obtain help but resumed care alone once the resident calmed, and that the resident pulled himself off the bed while holding the bed frame during incontinence care, resulting in the fall and injury.
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