Failure to Provide Safe Assistance During Incontinence Care Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe assistance and adequate supervision during incontinence care, resulting in a fall with minor injuries. The facility’s Falls – Clinical Protocol policy required identification of residents at risk for falls and assessment and documentation of falls and related factors. Resident #1, an older adult with severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact and required substantial to maximal assistance with toileting and other ADLs. A fall risk assessment identified her as a high fall risk, and her fall care plan cited risk factors including respiratory failure, COPD, and chronic pain. The resident’s ADL care plan noted a self-care performance deficit and need for staff assistance, but the bed mobility intervention did not specify the level of assistance or number of staff required. The fall care plan, however, included an intervention that two staff members were to provide incontinence care. On the date of the incident, a CNA was providing incontinence care when the resident rolled out of bed, landing on her lower extremities. The resident reported right shoulder pain, and the nurse observed multiple skin tears on the toes and a right knee abrasion. An IDT note later described that the resident lifted her right leg, her weight shifted, and she rolled left and slid out of bed onto her knees during incontinence care. The resident’s representative reported that the resident stated an unknown CNA kept pushing her to roll over during incontinence care, leading to her falling off the bed, and that a nurse entered and saw the CNA pulling the resident up from the floor by her right arm despite the resident’s complaints of pain. The representative also reported abrasions or bruising on every toe of the resident’s right foot, with bandages applied, and that the facility notified her later that the resident had a fall and was fine, without informing her of injuries. Staff interviews showed inconsistency between the care plan requirement for two-person assistance during incontinence care and staff understanding of the needed level of assistance, with the DON stating the resident required one-person assistance for turning in bed prior to the fall. Review of the electronic medical record revealed no nursing progress notes documenting the fall event on the date it occurred.
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