Failure to Ensure Safe Bed Mobility and Timely Medical Response Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not ensuring safety during bed mobility in accordance with assessed and care planned needs. One resident, who was severely cognitively and physically impaired, dependent on staff for all activities of daily living, and required two-person assistance for bed mobility, sustained a fall from bed during care when only one staff member was present. The staff member was unaware of the resident's two-person assist requirement and did not request help, citing that other staff were busy and that she had not received training specific to the resident. The resident fell while the staff member was preparing to provide care, and the incident was not properly assessed or documented by nursing staff at the time. Following the fall, the resident experienced acute pain that was not promptly addressed. There was a delay in both the assessment and management of the resident's pain, as well as in obtaining necessary diagnostic imaging. The resident was not seen by a physician in a timely manner, and an ordered X-ray was not completed as expected. The resident was eventually transferred to the hospital, where a hip fracture was diagnosed. Upon return to the facility, there were further delays in pain management due to issues with medication orders and communication, resulting in the resident experiencing ongoing pain and distress. Interviews and record reviews revealed inconsistencies and confusion among staff regarding the resident's care plan and required level of assistance. Documentation was lacking for post-fall assessments, pain management, and follow-up care. The resident's family was not promptly notified of the fall, and there were issues with communication and continuity of care between facility staff and the resident's primary care provider. The failure to follow the care plan, provide adequate staffing and training, and ensure timely medical intervention resulted in a worsened condition for the resident and constituted neglect.