Failure to Prevent Fall and Injury During Bed-Level Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision during incontinence care, resulting in a resident’s fall and subsequent femur fracture. The resident was an older female with multiple significant diagnoses, including prior cerebral infarction with hemiplegia/hemiparesis on the left side, osteoporosis, reduced mobility, muscle weakness, lack of coordination, and a prior displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments documented that she was dependent on staff for rolling left and right in bed and had a history of falls with major injury. Her care plan identified ADL self-care performance deficits, need for staff assistance with bed mobility and colostomy/incontinent care, and a requirement for two-person assistance with transfers using a Hoyer lift, as well as fall risk related to history of falls, hypotension, and generalized weakness. On the date of the incident, the resident was receiving a bed bath and incontinent care from one CNA. According to the ADON’s progress note, during the bed bath the resident used a mobility bar to turn and misjudged the width of the bed, causing her momentum to roll off the bed before staff could stop her, and she landed on the floor on her left side. The CNA later stated she had finished the bed bath and was positioning the resident on her right side to apply an adult brief while the resident held the mobility bar. The CNA reported asking the resident three times if she had a firm grasp on the bar, and as soon as she placed the brief under the resident, the resident rolled off the bed and landed on her left side in a seated position. The resident reported that the CNA was applying lotion to her legs before she was pushed out of bed, clarified that she did not believe it was intentional, and stated that the CNA was not following protocol. The resident also stated that there needed to be two people when turning her and that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care. Following the fall, nursing staff documented that the event was witnessed and that the resident initially complained of shoulder pain. Vital signs were taken, and an x-ray of the left shoulder was ordered and later read as showing no fracture or acute abnormality. Another nurse reported performing range of motion on both arms and legs, checking the resident’s head, and obtaining vital signs at the time of the fall but did not document this assessment because the resident was not on her assignment. Over the next days, the resident complained of bilateral leg, knee, and ankle pain, and the NP ordered STAT x-rays of both femurs, knees, and ankles, which were read as showing osteoporotic bones and osteoarthritis but no acute fractures or dislocations. The resident stated she complained of left leg pain for three days. Later, at the request of a family member due to ongoing leg/knee pain, the resident was sent to the hospital, where a CT scan of the left lower extremity revealed a comminuted, mildly impacted, intra-articular fracture of the distal femur. The family member reported not being informed of the fall and only learning of it before insisting on hospital evaluation. The facility’s fall management policy stated that residents are to receive appropriate assessment and interventions to prevent falls and minimize complications if a fall occurs, but the report findings describe that the facility failed to prevent the fall during care and to keep the environment as free of accident hazards as possible for this resident.
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