Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness, who was receiving hospice services, experienced a fall from their bed during care. The resident reported that the hospice aide was providing care alone and, while turning the resident in bed, the resident rolled off onto the floor. The resident's care plan specifically required two staff members to assist with bed mobility due to their fall risk, an intervention that was documented and in place prior to the incident. Facility records, including the incident/accident report and progress notes, confirmed that the hospice aide provided care without the required second staff member. The Director of Nursing acknowledged awareness of the incident and stated that the expectation was for care to be provided with two-person assistance, as outlined in the resident's care plan. The facility's policy also required care plans to be developed and implemented based on fall risk assessments.