Failure to Provide Adequate Assistance for Bed Mobility Results in Resident Fall
Penalty
Summary
Facility staff failed to ensure adequate assistance for bed mobility for a resident with significant physical impairments, including multiple sclerosis, hemiplegia, hemiparesis, muscle wasting, and lymphedema. The resident's Minimum Data Set (MDS) assessment indicated a need for extensive assistance from two or more staff for bed mobility, but the care plan did not address this requirement. During morning care, a CNA who was not regularly assigned to the resident attempted to reposition the resident alone using a drawsheet, resulting in the resident rolling off the bed and falling to the floor. The resident, who was cognitively intact, reported that she was accustomed to having two or more staff assist with repositioning and expressed concern about staffing levels. She described the incident, stating that she was turned to her right side and continued rolling off the bed, landing on the floor. The CNA confirmed that she was providing care alone, pulled too hard on the drawsheet, and the resident fell. The CNA left the resident on the floor to seek help, and other staff, including the DON and NP, responded to assess and assist the resident back into bed. The facility's fall investigation records initially did not include documentation of this incident, and the DON later added the information after being questioned. Interviews with staff and the resident confirmed that the care plan did not specify the need for two-person assistance for bed mobility, and the incident occurred due to inadequate assistance during repositioning. The resident experienced pain and swelling in her legs following the fall and expressed apprehension about future care.