Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who was severely cognitively impaired and dependent on two staff members for dressing, toileting, bed mobility, and positioning was not provided with the required level of staff assistance during care. The resident, who had diagnoses including dementia and Parkinson's disease, was care planned to require two staff for all bed mobility and positioning tasks due to significant physical and cognitive limitations. On the evening of the incident, a CNA provided care to the resident alone, despite the care plan and Kardex specifying the need for two staff members for such activities. During the provision of care, the CNA positioned the resident on their side in bed and then turned away to retrieve a supply that was out of reach, leaving the resident unattended. The bed was in a high position, and the resident was left on their side, which was an unsafe position given their inability to assist with movement or maintain balance. While the CNA was away from the bedside, the resident rolled off the bed and fell to the floor, sustaining a laceration to the back of the head and a closed displaced fracture of the right femoral neck, requiring transfer to the hospital. Interviews with staff confirmed that the resident was totally dependent on staff for all care and that two caregivers should have been present during the incident. The CNA involved misunderstood the care plan instructions, believing that two-person assistance was only required for certain movements and not for all bed mobility or positioning. Other staff and management confirmed that the care plan was clear and that the required level of assistance was not provided at the time of the incident, directly leading to the resident's fall and injury.