Failure to Ensure Adequate Supervision and Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had significant medical conditions including chronic respiratory failure, COPD, high BMI, and diabetes, sustained a fall from bed during incontinence care. The resident was identified in the most recent Minimum Data Set (MDS) assessment as requiring extensive assistance from two or more persons for bed mobility. However, at the time of the incident, only one Certified Nursing Assistant (CNA) was providing care, and the resident was rolled to her side for a brief change, resulting in her falling from the bed. The care plan and documentation regarding the required level of assistance for the resident were inconsistent and unclear. Interviews with staff revealed confusion about whether the resident required a one-person or two-person assist for bed mobility and brief changes. Some CNAs reported that the resident was often changed by one person, sometimes by two, and that the resident herself sometimes requested only one CNA. The MDS Coordinator confirmed that the resident's last quarterly assessment indicated a need for two-person assistance, but this was not consistently reflected in the care plan or communicated to all staff. The Director of Nursing (DON) acknowledged that prior to the fall, the resident's assistance status was not listed in the KARDEX or care plan, and staff relied on informal sources such as the "CNA Bible" or verbal communication to determine assistance needs. At the time of the fall, the resident's bed was in an elevated position, which was her preference, and she was on an air pressure mattress (APM) that was in alternating mode. The CNA providing care stated she had performed one-person brief changes for this resident multiple times without issue until the incident. The lack of clear, updated documentation and communication regarding the resident's assistance needs, combined with the use of only one staff member for a resident assessed as needing two-person assistance, directly led to the fall and resulting injuries, which included multiple fractures and a head laceration.