Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Harm
Penalty
Summary
The facility failed to provide adequate supervision and assistance during care for a resident who required extensive help with bed mobility, resulting in actual harm. The resident, who had a history of cerebral infarction, psychomotor deficit, hemiplegia, and hemiparesis affecting the right side, was assessed as needing the assistance of two or more staff members for turning and repositioning in bed. Both the care plan and bedside Kardex clearly indicated this requirement. The resident also had significant cognitive impairment, being rarely understood and unable to recall basic information, making them non-interviewable and highly dependent on staff for care. Despite these documented needs, only one nurse aide was present during the provision of incontinent care when the incident occurred. The nurse aide attempted to turn and reposition the resident alone, during which the resident's legs slipped off the bed and the aide was unable to prevent the resident from sliding to the floor. The bed was positioned high for care, and the resident was rolled onto their weak side, further increasing the risk. The nurse aide and the charge nurse both stated they were unaware at the time that two-person assistance was required for this resident's bed mobility and repositioning. As a result of this lack of adequate supervision and failure to follow the resident's care plan, the resident fell from the bed, sustained a compound fracture of the right femur, and required hospitalization and surgical repair. The incident was witnessed and documented in the facility's incident report, and subsequent interviews with staff confirmed that the required level of assistance was not provided at the time of the fall.