Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with osteoporosis, atrial fibrillation, and dementia sustained a left distal tibia and fibula fracture after rolling out of bed during incontinence care. The resident was on an anticoagulant and had a care plan indicating the need for assistance from two staff members for activities of daily living (ADLs) due to impaired mobility, poor safety awareness, and impulsiveness. However, at the time of the incident, only one nurse aide was providing care, and the resident was rolled away from the aide, resulting in the resident sliding off the bed and falling to the floor. The nurse aide involved did not request assistance from another staff member, despite the care guide indicating a two-person assist was required for ADLs. The aide also rolled the resident away from herself, rather than towards herself, which contributed to the resident's fall. The bed was raised to the aide's waist height, and the resident was positioned in the middle of the bed before care began, but during the process, the resident attempted to assist and rolled too far, leading to the fall. At the time of the incident, there was a discrepancy between the physical therapy discharge summary, which indicated the resident required supervision/touch assistance from one staff member for bed mobility, and the care plan and care guide, which still required two-person assistance. The therapy department had notified nursing of the change, but the care plan and care guide had not yet been updated. This lack of timely communication and failure to follow the existing care plan resulted in the resident not receiving the required level of assistance, directly leading to the accident and injury.