F0689

G

Failure to Safely Position Resident During ADL Care Resulting in Fall and Fractures

Clarkston, Michigan Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care in a safe manner to prevent an accident during ADL care, resulting in a resident’s fall from bed and subsequent fractures. The resident was an older adult with recent and significant medical issues, including a displaced intertrochanteric fracture of the right femur requiring surgery, a fracture of the manubrium, multiple right rib fractures, trigeminal neuralgia, Meniere’s disease, and psychosis. A recent MDS showed the resident had intact cognition, used a walker and wheelchair, required substantial/maximal assistance for bed mobility, and was dependent for toileting hygiene. The care plan identified the resident as at risk for falls related to multiple conditions, including recent fractures, and included an intervention to encourage and assist the resident to be positioned in the middle of the bed prior to rolling, as well as a transfer status of one-person assist with a two-wheeled walker and non-ambulatory status.

During the night, while a CNA was providing incontinence/ADL care, the resident rolled out of bed and onto the floor. The nurse’s progress note documented that the CNA reported the resident rolled out of bed in the middle of ADL care and was found on the floor on her left side, with a broken left pinky nail and later complaints of left shoulder pain. The CNA’s written witness statement and subsequent interview described that the bed was elevated to a working height, the resident was being turned for care, and the CNA rolled the resident away from herself. The CNA reported that the resident began exhibiting unusual jerking and jolting movements and then fell to the floor. The CNA acknowledged rolling the resident away from her during repositioning and stated she did not stop care to seek additional help when the resident’s movements became unusual, explaining that she believed others were busy and she informed the nurse afterward. The DON later stated that the expectation is to roll residents toward the caregiver or get help, and to stop care and notify the nurse when there is a sudden change in condition.

Following the fall, the resident complained of pain in the shoulder, ribs, and hip, and later reported dizziness, new visual changes, and a different type of headache. An NP note documented right upper extremity weakness, edema, limited arm elevation, bruising to the right temple, and ongoing rib pain, with the resident reporting she had hit her head during the fall. The NP ordered transfer to the hospital for CT imaging due to head injury complaints. Hospital CT imaging identified a minimally displaced fracture of the right anterior superior manubrium and fractures of the right 1st and 2nd ribs, and the hospital H&P recorded that the resident stated she rolled out of bed as she was being turned by staff. The facility’s internal investigation concluded that the resident rolled too far and slid off the bed during repositioning, characterized the fall as not preventable, and documented that the bed height was appropriate, but did not address the CNA’s description of sudden jerking/jolting movements, the elevated bed during care, or the technique of rolling the resident away from the caregiver despite the resident’s recent hip fracture and need for substantial assistance with bed mobility. Discrepancies were noted between the investigation documents and the clinical record regarding staff presence, continence status at the time of the incident, and environmental details.

The surveyor also identified that the facility did not have a specific written policy on positioning, with corporate clinical staff stating that positioning was considered a basic skill staff should know. The facility’s QA tool for the fall with fracture indicated the fall was deemed not preventable and referenced new interventions, but left sections for staff education and QA committee review incomplete. The investigation and documentation did not reconcile or fully incorporate the CNA’s account of the resident’s unusual movements during care, nor did it analyze whether the resident’s functional limitations and recent right hip fracture affected safe repositioning during ADL care. These actions and omissions, including the manner of positioning and rolling the resident away from the caregiver on an elevated bed, the failure to stop care and seek assistance when the resident’s condition changed, and the incomplete and inconsistent internal investigation, led to the cited deficiency for not ensuring care was provided in a safe manner to prevent accidents.