Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall and Fatal Injury
Penalty
Summary
A deficiency occurred when a resident with right-sided weakness from a stroke, severe cognitive impairment, and a care plan requiring assistance from two staff members for bed mobility was not provided the necessary level of staff assistance. The resident was dependent on staff for turning and repositioning in bed, had upper and lower extremity limitations, and was at risk of injury. Despite these documented needs, a Certified Nurse Aide (CNA) attempted to change the resident's bed sheets alone, without the required second staff member present. During the incident, the CNA rolled the resident onto their left side and proceeded to change the fitted sheet, which was too small for the mattress. This caused the mattress to curl up, resulting in the resident rolling out of bed and landing on their knees. The CNA attempted to support the resident after the fall, but no other staff were present at the time. The resident sustained bilateral distal femur fractures and was subsequently transferred to the hospital, where they died the following day due to traumatic hemorrhagic shock. Interviews and record reviews revealed that the CNA did not review the resident's care plan or CNA Care Card to confirm the required level of assistance, instead relying on verbal information from other staff. The CNA had received training on safe patient handling and the use of care plans but was unfamiliar with the facility's procedures for reviewing these documents. Other staff members had informed the CNA of the resident's need for two-person assistance and had offered to help, but the CNA did not seek assistance when providing care.