Failure to Provide Safe Bed Mobility Assistance Resulting in Resident Fractures
Penalty
Summary
A deficiency occurred when staff failed to provide safe bed mobility assistance to a resident diagnosed with morbid obesity and generalized osteoarthritis, who was dependent on staff for bed mobility. The resident required assistance due to general weakness, immobility, and decreased activity endurance. During morning care, a CNA attempted to assist the resident in rolling to her side, but the resident's leg fell off the bed. The CNA, who was physically smaller than the resident, was unable to safely reposition the resident and attempted to lift her leg back onto the bed. This resulted in both the resident and the CNA falling from the bed to the floor, with the resident's legs crossing during the fall. As a result of the fall, the resident sustained fractures to both the left and right femur, requiring hospitalization. Multiple staff interviews and progress notes confirmed that the CNA was not able to manage the resident's weight and size during the transfer, and the incident occurred while the resident was being prepared to get out of bed. The resident was subsequently admitted to the hospital with closed fractures of the proximal left femur and distal right femur, as well as a left urethral stone. The incident was witnessed by the resident's roommate and corroborated by nursing staff and the nurse practitioner.