Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to safely turn a resident in bed, resulting in the resident rolling off the bed and sustaining a right femur fracture. The resident had significant medical conditions, including functional quadriplegia, morbid obesity (BMI 50-59.9), reduced mobility, muscle wasting, and was non-ambulatory. Care plans indicated the resident required extensive assistance from two staff for mobility and transfers, and was dependent on staff for bed mobility and toileting. However, interventions related to bed mobility and transfers had not been updated in over two years, and documentation showed the resident was dependent on staff for these activities. On the day of the incident, a CNA was providing care to the resident alone and attempted to turn the resident in bed. The resident reported that her leg slid off the bed while being turned, and she subsequently rolled off the bed onto the floor. The CNA stated that the resident turned herself and that she did not touch the resident, but also confirmed she was alone during the care. Interviews with facility staff, including the Therapy Director and Assistant Director of Nursing, confirmed that staff should not roll residents away from themselves and that, given the resident's weight and immobility, there was a risk of the resident's leg sliding off the bed if not properly supported. The investigation revealed that no staff member was present on the opposite side of the bed to prevent the resident from falling, and the resident was not rolled toward the staff member as recommended. The facility's policy required care to be provided to meet residents' physical needs, including adequate assistance with activities of daily living. The failure to follow these procedures and provide adequate supervision directly led to the resident's fall and injury.