Failure to Provide Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, admitted with end stage renal disease and diabetes and receiving dialysis, did not receive the required level of assistance for bed mobility as specified in their care plan. The care plan, updated on 11/20/2024, indicated that the resident required two-person extensive assistance for repositioning and turning in bed. However, on 04/12/2025, the resident was assisted by only one CNA during bed mobility, contrary to the care plan instructions. As a result of this deviation from the care plan, the resident slid from the bed while being changed, fell to the floor, and sustained a fractured right humerus. Interviews with staff and facility leadership confirmed that staff are expected to follow the care plan and use the Kardex to determine the required number of staff for such tasks. The incident investigation determined that the CNA performed bed mobility alone, which was not in accordance with the resident's documented needs.