Improper Bed Positioning and Single‑Staff Assist During Bed Bath Leads to Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during personal care, resulting in a resident sustaining a closed head injury and a right shoulder dislocation with a right humerus fracture. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, vascular dementia, generalized muscle weakness, osteoarthritis, and chronic pain managed with scheduled acetaminophen. She was non‑ambulatory, dependent on staff for ADLs, and weighed 241 pounds. Her care plan identified risks related to immobility, self‑care deficits, and chronic pain, with interventions including total dependence on staff for bathing and turning/repositioning in bed as necessary. On the morning of the incident, the assigned nurse aide entered the resident’s private room to provide a bed bath. The bed was initially positioned with the left side against the wall and was raised to the aide’s waist height. The aide reported locking the bed, then unlocking it to move it away from the wall to gain access from both sides, and believed she had re‑locked it afterward. As she stood on the left side of the bed and attempted to roll the resident toward the right, both the bed and the resident began to move because the bed wheels were not actually locked. The resident’s head, shoulders, and legs were left hanging off the bed with most of her weight unsupported, while the aide held her by the torso and yelled for help. Two additional nurse aides responded and attempted to assist. One aide held the resident’s legs, another held her head and arm, and they noted that the resident’s leg was stuck between the geri‑chair and the bed and that the bed continued to move, with limited space to maneuver due to the proximity of the nightstand and geri‑chair to the bed. The three aides were unable to lift or push the resident back onto the bed and slowly lowered her to the floor, where she ended up face down with her right arm underneath her. Staff accounts indicated the resident may have hit her head on the nightstand, and she complained of head and right shoulder pain. When nursing staff arrived, the resident was found face down on the floor with a large knot on her forehead and complaints of right arm pain. She was subsequently sent to the ED, where she was diagnosed with a fall, closed head injury, right shoulder dislocation, and right humerus fracture. The Director of Nursing later stated that the aide should have ensured the bed was locked and that, given the resident’s size and physical limitations, she should have been assisted by two staff during care.
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