Failure to Provide Adequate Supervision During Incontinence Care Resulting in Fall
Penalty
Summary
Facility staff failed to provide adequate assistance and supervision during incontinence care to prevent a fall for one resident. The resident had diagnoses including diabetes, high blood pressure with episodes of orthostatic hypotension, and impaired mobility and self-care related to lumbar spine fusion. An admission MDS with an ARD of 1/6/26 documented a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision-making. According to the Rehab Director, the resident was unable to tolerate therapy, was resistant to sitting up on the side of the bed or in a wheelchair, had episodes of low blood pressure, reported feeling ill while sitting up, and would vomit. Prior to the fall on 3/6/26, the resident’s care plan did not include a problem related to resistance to care. On 3/6/26 at 4:30 AM, while a CNA was providing incontinence care, the resident experienced a witnessed fall from the bed to the floor. Nurse’s notes documented that the resident was resisting care, attempted to get out of bed, and slid off the bed to the floor, requiring two staff members to assist her back into bed. The DON later stated that, in this situation, the CNA should have stopped care when the resident became resistant, reminded the resident that she required assistance to get out of bed, ensured the resident was safe, and then reapproached the resident. Family Member #1 reported observing staff working to transfer the resident back to bed after the fall. These findings show that staff did not provide adequate supervision and assistance during incontinence care to prevent the fall.
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