Inadequate Supervision During Bed Mobility Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and reassessment of a resident's ability to assist with bed mobility following a room change and changes in level of consciousness. The resident, who had diagnoses including heart failure, below-the-knee amputation, obesity, and impaired functional mobility, was dependent on staff for transfers, toileting, and bed mobility. The care plan indicated the need for extensive assistance from one to two staff for bed mobility. However, staff determined the number of assisting personnel based on their assessment of the resident's ability to help during care, which varied depending on the resident's alertness and environment. After a room change, the resident's bed was no longer against the wall, removing a support the resident previously used for stability during care. During a bed linen change, a single nursing assistant attempted to provide care while the resident was drowsy and unable to remain awake. The resident was rolled toward the edge of the bed and subsequently fell headfirst onto the floor, resulting in a subdural hematoma and hospitalization. Staff interviews revealed inconsistent practices regarding the number of staff required for bed mobility, with some relying on the resident's ability to assist and others always using two staff for safety. The incident was attributed to inadequate supervision, failure to reassess the resident's needs after environmental changes, and not ensuring sufficient staff assistance during care.