Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A resident with diagnoses including pressure ulcer, hypertensive heart disease with heart failure, dementia, type 2 diabetes mellitus, and major depressive disorder was admitted to the facility and required substantial to maximum assistance with bed mobility, as documented in the resident's MDS and physician orders. The resident was specifically ordered to have assistance from two staff members for bed mobility. During a wound care procedure, an LPN performed the task alone without a second staff member present. While the resident was being repositioned on an air mattress, she began to slide off the bed. The LPN attempted to prevent the fall but was unable to do so, resulting in the resident being lowered to the floor. Following the incident, the resident reported right hip pain and was subsequently sent to the hospital, where a right femoral fracture was diagnosed, necessitating a total hip replacement. Documentation and interviews confirmed that the LPN was not aware of the two-person assist requirement for bed mobility at the time of the incident. The facility's policy on fall management and the resident's care plan were not followed, leading to the resident's fall and injury.