F0689

G

Failure to Ensure Safe In‑Bed Turning During Incontinent Care Resulting in Fall With Fractures

Shelby, North Carolina Survey Completed on 03-12-2026

Penalty

Fine: $16,720

Summary

The deficiency involves the facility’s failure to ensure safe in‑bed care and adequate supervision during incontinent care for a resident with right‑sided hemiplegia and vascular dementia, resulting in a fall with fractures. The resident had a history of stroke with hemiplegia and hemiparesis affecting the right dominant side, vascular dementia, vitamin deficiencies, and demineralization, and was assessed as dependent on staff for all ADLs, mobility, and transfers, and frequently incontinent of bowel and bladder. A bed rail assessment and care plan documented the use of bilateral half side rails as an enabler to assist with positioning, mobility, and support in bed, and interventions included giving verbal cues and using bilateral half side rails to enhance mobility and safety. Therapy and the NP confirmed the resident was capable of using the half side rails for bed mobility but still required staff assistance to ensure her hand was securely placed on the rail before turning or repositioning.

On the morning of the fall, a nurse aide on night shift entered the resident’s room around the end of the shift to provide incontinent care and fix the bed pad. The aide reported that the bed was raised to about waist height, both half side rails were up, and she stood on the side of the bed closest to the door. While attempting to fix the bed pad, she rolled the resident away from her toward the window, assuming the resident would grab and hold the half side rail as she normally did. The aide did not instruct or ensure that the resident had reached for and secured her hand on the side rail before initiating the turn. During the roll, the resident’s left leg crossed over the right, her hand slipped off the side rail, and her legs continued over the side of the bed, causing her to roll off the bed and onto the floor. The aide attempted to stop the fall but was unable to do so.

Nursing staff responding to the incident found the resident on the floor on her right side or partially on her right abdomen, facing the window, with her right arm under her torso. Initial assessments by nurses noted a small abrasion and pain to the right knee, no immediate swelling, and no obvious deformities or leg length discrepancies; the resident was able to move extremities within her normal limits and follow commands. Later observations by another aide and nurses identified mild swelling and pain in the right wrist and continued pain in the right knee, and the resident reported significant pain despite scheduled and PRN pain medications. The resident and multiple staff consistently reported that the fall occurred when the aide rolled the resident during care, the resident’s hand slipped from the side rail, and her legs kept going over the side of the bed. Hospital imaging subsequently revealed fractures of the right wrist and right knee, and the resident stated she believed this was the worst fall she had suffered.

Interviews with the DON, Director of Therapy, and NP confirmed that staff were expected to ensure the resident’s hand was securely on the side rail before turning or repositioning her in bed and that the aide did not do so at the time of the incident. The DON stated that NA #1 should have assured the resident’s safety by making sure her hand was secured onto the side rail before beginning care or fixing the bed pad. The NP and Director of Therapy reiterated that, although the resident could use the side rails to assist with mobility, staff were responsible for assisting and confirming proper hand placement on the rail prior to turning. The failure to ensure secure use of the side rail and to provide safe in‑bed assistance during incontinent care directly preceded the resident’s fall from the raised bed and the resulting fractures to her right wrist and right knee.