Inadequate Supervision During Bed Mobility Leading to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision during bed mobility for one resident during personal care, resulting in a fall from bed. The resident had been newly admitted with diagnoses including diabetes, hypertension with heart failure, and chronic kidney disease. On admission, documentation indicated the resident required maximum assistance of two staff for transfers and assistance of two for bed mobility to roll. During a full bed bath, a nursing assistant pulled the resident toward her and turned the resident onto his side, then turned away to get a sheet and brief. While the assistant’s attention was diverted, the resident reached for a nearby chair, struck the chair, and then fell to the floor. A progress note documented that the resident rolled out of the left side of the bed during personal care, hit his face on the armrest of a chair at the head of the bed, and then hit the floor. The resident was observed lying supine with head and shoulders resting against the chair, with moderate bleeding from a laceration on the bridge of the nose, a laceration below the right eye, and subconjunctival bleeding in the right eye. The resident was able to state full name and date of birth and complained of double vision and pain in the right eye. Based on review of facility policies, clinical records, and staff interviews, the facility acknowledged that it failed to provide adequate supervision during bed mobility for this resident, and this was cited as past noncompliance.
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