Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
Resident 14, who had diagnoses including morbid obesity, hemiplegia, and hemiparesis, required extensive assistance by two staff members for bed mobility and repositioning, as documented in the resident's care plan and Minimum Data Set (MDS). Despite these documented needs, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without requesting the required assistance. During this unsupervised care, the resident was rolled out of bed and fell to the floor, resulting in a left femur fracture. The resident's bed was also noted to be in a high position at the time of the fall. Interviews and record reviews confirmed that the CNA was aware of the need for a second person to assist but did not seek help. The resident was subsequently found screaming in pain and was transferred to the hospital, where the fracture was confirmed. Staff interviews further corroborated that the resident consistently required two to three persons for safe repositioning due to her condition, and the Director of Rehabilitation stated the fall was avoidable if proper assistance had been used.