Failure to Provide Adequate Staffing and Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
The facility failed to provide the required number of staff to ensure resident safety during bed mobility, as outlined in the care plans for multiple residents. One resident, who was severely contracted, bedbound, and dependent on two-person assistance for all activities of daily living, experienced a fall from bed while only one staff member was present during care. The staff member assigned was unfamiliar with the resident’s care needs, had not received specific training, and did not request additional assistance due to staffing shortages and being unaware of the resident’s two-person assist requirement. The resident fell to the floor during care, and staff subsequently assisted the resident back to bed without a documented assessment or vital signs being taken at the time of the incident. Following the fall, the resident experienced ongoing and severe pain, which was not consistently addressed or documented by nursing staff. Pain medication was not always administered as ordered, and there were delays in both pain assessment and intervention. The resident’s family was not promptly notified of the fall, and there were issues with communication regarding the resident’s hospital admission, including the use of the wrong name. The resident was eventually transferred to the hospital after continued complaints of pain and was diagnosed with a right hip fracture. The hospital determined the resident was not a candidate for surgery due to contractures and comorbidities, resulting in ongoing physical and psychosocial pain. The facility also failed to ensure timely physician assessment and follow-up after the fall. There was no evidence that the resident was seen by a physician throughout the month following the incident, and an ordered X-ray was not completed in a timely manner. Documentation of post-fall assessments, pain management, and care plan interventions was lacking. Interviews with staff and the resident’s family confirmed that the resident’s pain was not adequately managed, and the care plan interventions were not consistently implemented. These failures resulted in a worsened condition for the resident and created a situation of Immediate Jeopardy.