Failure to Provide Required Two-Person Assistance for Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, was not provided with the required assistance for bed mobility. The resident's care plan, physician orders, and Minimum Data Set all indicated a need for a full body mechanical lift and assistance from two staff members for transfers, hygiene, and repositioning in bed. Despite these documented requirements, a nurse aide attempted to provide care and reposition the resident alone. During this process, the aide lost balance, and the resident rolled out of bed, sustaining a partial head laceration and a headache, which required hospital evaluation. Facility policies required staff to use appropriate transfer techniques and to assess and provide the necessary assistance for each resident. Staff interviews confirmed that aides are expected to follow the care plan and obtain help when two-person assistance is required. The nurse aide involved admitted to typically seeking help but failed to do so on this occasion. The incident was confirmed by the resident, staff, and facility leadership, who acknowledged that the appropriate assistance was not provided, resulting in the resident's fall.