Failure to Provide Adequate Supervision During Bedside ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free environment during ADL care for one dependent resident, resulting in a fall with fractures. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness, and was coded on the MDS as dependent for rolling left and right in bed, meaning the helper did all of the effort. The resident was also coded as rarely/never understood, so no BIMS was completed. Facility orders included the use of floor mats to the side of the bed while the resident was in bed for safety related to frequent falls. On the date of the incident, a CNA was providing ADL care to the resident while the resident was in bed. According to nursing documentation and staff interviews, the CNA turned her back to rinse a washcloth, during which time the resident rolled out of the bed onto the floor. LPN interview and nursing notes indicated that the bed had not been lowered and fall mats were not in use at the time of the fall, despite existing orders for floor mats. Staff, including the MDS nurse, Rehabilitation Manager, and DON, stated that the resident was totally dependent for ADLs, would not follow commands, and that the CNA should have ensured the resident was safely positioned in the middle of the bed before turning away. Following the fall, nursing documentation described that the resident was assessed and initially noted to have a small skin issue on the left lower arm, with no immediate signs of distress or pain. Over the next several days, nurses documented bilateral lower leg and ankle swelling, bruising, and obvious pain during ADL care. X‑rays of the bilateral ankles and feet were ordered and performed, and radiology results later identified acute‑appearing fractures of the distal tibia and fibula with posterior and medial angulation, as well as a fibular fracture. The resident was subsequently sent to the hospital and was reported to be admitted with bilateral tibial fractures. The facility’s own fall prevention and management policy referenced assessing fall risk factors including the resident’s current ADL status, but the actions taken during the ADL care did not prevent the fall for this dependent resident.
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