Resident Rolled Out of Bed During Incontinence Care Due to Improper Positioning and Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during incontinence care, resulting in a resident rolling out of bed and hitting the floor face first. The resident had diagnoses including non-traumatic brain dysfunction, Alzheimer’s disease, non-Alzheimer’s dementia, and seizure disorder, and a quarterly MDS documented severe cognitive impairment with a need for substantial to maximal assistance for rolling in bed. A physical therapy note indicated the resident required partial to moderate assistance for rolling, and the physical therapist later stated the resident required moderate to maximum assistance of two staff members with everything, including direction and verbal cues, and that at discharge from therapy the resident still required one-person assistance with bed mobility. Despite these documented needs, the resident’s care plan and care guide indicated she was independent with bed mobility (rolling left and right), requiring only verbal cues and occasional hands-on prompting, and listed her as independent for rolling left and right. On the morning of the incident, a nurse aide entered the resident’s room to provide incontinence care and dressing assistance. He reported that he informed the resident he was going to change her and roll her onto her side, then picked up the bed pad and pulled it upward, rolling her onto her left side and away from him. As her weight shifted, she continued rolling off the bed and onto the floor face first while he was positioned across the bed and unable to catch her in time. The resident was found lying face down on the carpeted floor next to the bed with an abrasion to the right side of her forehead. Staff interviews, including with the nurse aide, Nurse #1, the DON, and the Administrator, confirmed that the resident was cognitively impaired, required verbal cues and assistance with bed mobility, and that the aide had been informed earlier that morning that the resident required two-person assistance with transfers. They also confirmed that during the incident the aide rolled the resident away from himself using the bed pad rather than toward himself while providing incontinence care, which led to her rolling off the bed onto the floor.
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