Head Laceration During Incontinence Care Due to Improper Positioning Near Wall Trim
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained safe from accident hazards during incontinence care, resulting in the resident striking her head and sustaining a laceration requiring six staples. The resident had diagnoses including muscle weakness, Alzheimer’s disease, dementia, and muscle wasting and atrophy, and a care plan dated 11/18/25 indicated she required assistance with activities of daily living, including proper positioning while in bed. An MDS assessment dated 1/28/26 documented that the resident required substantial to maximal assistance to roll from back to side and return to back while in bed. On 2/13/26, while a CNA was completing care, the resident was rolled toward the wall and her head was bumped on the wall trim, causing a laceration to the top of her head. Facility documentation of the incident stated that the resident was placed on her back on an inflated low air loss mattress with bolsters, with the bed raised to the CNA’s waist height for incontinent care. As the CNA started to roll the resident to the right side, the resident’s head struck the chair rail/wooden strip on the wall, resulting in a 4.5 cm scalp laceration that required repair with six staples in the emergency room. Witness statements from an LPN and the CNA indicated that the CNA rolled the resident toward the wall and the resident’s head clipped the wooden strip on the wall, with the CNA acknowledging that it was a combination of rolling the resident too far and the inflated bed that caused the resident to roll further and hit the wall trim. The DON and Executive Director both stated that the combination of the inflated low air loss mattress and the CNA rolling the resident too far led to the resident’s head striking the wall trim, and it was noted that the resident could not roll on her own and needed staff assistance to do so.
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