Inadequate Supervision and Environmental Hazard During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment during incontinent care, resulting in a resident striking her head on a bedside table. The resident was an elderly female with severe cognitive impairment (BIMS score 00) and multiple diagnoses including dementia, Alzheimer’s disease, hypertension, chronic kidney disease, osteoarthritis, neuropathy, depression, anxiety disorder, muscle weakness, and cognitive communication deficit. Her care plan documented that she required two‑person assistance, was dependent for toileting hygiene and rolling left and right, and needed substantial to maximum assistance with bed mobility and personal hygiene. She was also bowel and bladder incontinent related to Alzheimer’s disease and dementia. During a routine incontinent/perineal care episode, two CNAs were turning the resident in bed when the incident occurred. According to CNA witness statements and nursing interviews, the resident began to move unpredictably or pushed with her upper body in the middle of the turn, almost falling off the bed. Although the CNAs were able to prevent her from falling to the floor by keeping her on the bed, they were unable to prevent her from hitting her head and face on the bedside table, which was positioned very close to the bed. Staff reported that the resident leaned or moved toward the side where the bedside table was located and struck the table with the side of her face, causing a laceration above the right eyebrow and subsequent bruising and swelling around the right eye. Post‑incident assessments and documentation confirmed the injuries and the circumstances of the event. A weekly skin check documented a bruise to the right eye and a laceration to the right eyebrow. The incident report completed by an LVN described a straight‑line injury above the right eyebrow, a swollen black eye, and bleeding that required cleansing and dressing, with vital signs within normal limits. Subsequent imaging of the facial bones showed no fracture, and neuro checks documented the resident as alert and oriented with normal vital signs. Observations later noted a large yellow discoloration bruise on the upper right side of the resident’s face. Interviews with the DON, ADON, physician, nurse practitioner, CNAs, LVN, and administrator consistently attributed the injury to the resident hitting her head on the bedside table during the turn for incontinent care, with the table described as being very close to the bed at the time of the incident.
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