F0689

G

Failure to Provide Safe Supervision During Incontinence Care Resulting in Fall and Head Injury

Kettering, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care, resulting in the resident falling from the bed. The resident had multiple diagnoses including toxic liver disease, congestive heart failure, anxiety disorder, Alzheimer’s disease, osteoarthritis, chronic kidney disease, sepsis due to E. coli, and dementia, with severely impaired cognition and dependence on staff for all ADLs. The comprehensive care plan identified an ADL self-care performance deficit related to confusion/dementia and noted the resident could be resistive to care, with interventions such as monitoring and anticipating care needs, using a scoop mattress, and assessing for fall risks. However, there was no specific fall risk care plan or fall-related interventions in place prior to the incident.

During incontinence care, CNA #355 provided personal care to the resident while the bed was in a high position. After completing care, CNA #355 turned away from the resident to reach for the bed remote to lower the bed, at which point the resident shifted or rolled and fell from the bed to the floor. According to staff interviews and documentation, the bed rails were down at the time of the fall, and the CNA had diverted attention away from the resident while the bed remained elevated. RN #134 was called to the room and found the resident on the floor with a laceration to the head and a significant amount of bleeding. The nurse’s note documented that the resident had decided to roll toward the floor during personal care while the bed was up high and the bed rails were down.

The resident was transferred to the ER, where records showed a closed head injury, scalp laceration measuring 3.2 cm, and cervical strain, with four staples placed in the scalp wound. Review of facility documentation showed that a fall risk assessment identifying the resident as high risk for falls was not completed until after the incident. The DON reported that falls were not reviewed by the full IDT and that, at the time of the incident, the nurse on duty was responsible for completing the fall risk assessment and immediate interventions, with only the DON reviewing falls afterward. The facility’s fall prevention policy required that each resident be assessed for fall risk upon admission and receive individualized interventions based on their level of risk, but the resident did not have a fall risk care plan or related interventions implemented before the fall occurred.