Resident Falls From Bed During Incontinent Care Due to Improper Positioning and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe provision of care and adequate supervision to prevent an accident for one resident identified as high risk for falls. The resident had Alzheimer’s disease, osteoarthritis, osteoporosis, abnormal gait and mobility, cognitive deficit, incontinence, and required extensive assistance for bed mobility. A fall risk evaluation completed on 12/9/25 identified the resident as high risk for falls. On 3/15/26 at 7:00 PM, while a CNA was changing the resident’s incontinent brief, the resident slid or rolled off the side of the bed and fell to the floor. The CNA reported that the bed was elevated to facilitate care, the brief was partially undone, and the resident was instructed to roll to the right side and grab the bed bar, at which point the resident rolled off the bed. The CNA stated she was positioned on the resident’s left side and did not have time to grab the resident as she fell to the right side. The LPN’s incident report and interview confirmed that only one staff member was present during the turning and changing, and that the resident fell off the right side of the bed while the CNA was working on the left side and pulling on lumpy sheets. The restorative nurse stated that staff should stand on the side of the bed toward which the resident is being turned to act as a barrier and help prevent rolling off the bed, and indicated that in this case the CNA should have been on the right side of the bed when the resident was turning. The resident’s daughter reported being told that the CNA pulled the sheet and the resident rolled off the bed, and stated that the CNA should have been standing in front of the resident rather than behind her. The resident was sent to the hospital for evaluation, and an X-ray of the left foot showed a fracture deformity of the second proximal phalanx of indeterminate age, with the physician unable to definitively link the fracture to this fall. The facility’s fall prevention policy states that each resident will receive services and care to ensure the environment remains as free from accident hazards as possible.
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