Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that appropriate assistance for bed mobility was provided to a resident, resulting in the resident rolling out of bed and sustaining bilateral leg fractures. The resident had significant medical conditions, including anemia, renal failure, osteoarthritis, and was non-ambulatory and bed-bound at baseline. Physician orders and the Minimum Data Set indicated the resident required total assistance of two persons for transfers via Hoyer lift and was dependent for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers, and staff did not consistently follow the documented requirements. On the day of the incident, a nurse aide was providing care to the resident alone and attempted to reposition the resident without the required second staff member. During this process, the resident rolled out of bed onto their knees while holding onto the bed rail. The resident was subsequently assisted back to bed by three staff members using a Hoyer lift. Following the fall, the resident developed extensive bruising and later complained of pain, which was initially managed with Tylenol. Despite ongoing documentation of bruising and pain, there was a lack of timely physician notification and assessment regarding the resident's injuries. Over the following weeks, the resident continued to exhibit bruising and pain, and eventually was found to have sustained bilateral leg fractures, requiring hospitalization and a blood transfusion due to a critically low hemoglobin level. Interviews with staff revealed confusion and inconsistency regarding the documentation and implementation of bed mobility and transfer assistance requirements. The facility's investigation confirmed that the appropriate assistance was not provided, and the care plan did not adequately address the resident's needs for bed mobility, directly contributing to the resident's injuries.