Failure to Provide Required Two-Person Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and muscle weakness, who was assessed as cognitively intact but required substantial to maximal assistance with toileting hygiene and bed mobility, was not provided care according to her documented needs. The resident's care plan specified a two-person assist for incontinent care and bed mobility. However, on the morning of the incident, a single nurse aide provided care without a second staff member present. During the process of turning the resident in bed, the resident slid off the side of the bed and was lowered to the floor by the aide. Following the incident, the resident was initially assessed and found to have no complaints of pain or visible injuries. However, a subsequent skin assessment revealed multiple areas of discoloration and abrasions on the resident's arms, abdomen, thigh, heel, toes, and back. The resident later began to complain of lower extremity pain, prompting a transfer to the emergency department for further evaluation. X-rays were negative for fractures or acute injury, and the resident was returned to the facility with no new orders. Interviews with facility staff, including nurses, the nurse practitioner, the DON, and the administrator, confirmed that the resident required two-person assistance for bed mobility and incontinent care. It was acknowledged by staff and leadership that providing care with only one aide was not in accordance with the resident's care plan and was unsafe. The nurse aide involved did not have a second person assisting at the time of the incident, which directly led to the resident sliding off the bed.