Failure to Follow Care Plan for Bed Mobility Assistance
Penalty
Summary
A deficiency occurred when staff failed to consistently implement and follow a resident's care plan interventions related to bed mobility. The resident, who had limited movement in both lower extremities and was totally dependent on staff for activities of daily living and mobility, required assistance from two staff members for bed mobility and positioning, as documented in the care plan. On one occasion during the overnight shift, a CNA provided incontinence care and repositioned the resident in bed without the required assistance from a second staff member. The CNA took hold of the resident's left leg, rolled the resident onto their side, and caused pain in the left hip, despite the resident's verbal request to stop due to pain. The resident reported that staff did not consistently provide the required two-person assistance for bed mobility and that the CNA was not gentle during care. The CNA acknowledged awareness of the care plan requirement but proceeded alone due to being too busy to get help, believing the resident could assist. The incident was reported, and interviews confirmed that the care plan was accessible to staff and specified the need for two-person assistance, which was not followed during the incident.