Failure to Provide Adequate Supervision and Safe Care During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations experienced two separate incidents of falling from bed during care, resulting in injuries that required emergency room evaluation and treatment. In the first incident, a nurse aide was providing a bed bath and rolled the resident away from herself, contrary to safe technique, and then turned to grab a towel, during which time the resident rolled off the bed. The bed was elevated approximately two feet from the floor, and the resident sustained a scalp hematoma. The resident was dependent on staff for bed mobility and required total assistance, as documented in her care plan. In the second incident, the same resident, now with a care plan updated to require two-person assistance for bed mobility, was being provided incontinence care by a single nurse aide. The aide did not check the resident's care plan or Kardex prior to providing care and did not request assistance, despite other staff being available. While attempting to clean the resident after a large bowel movement, the aide pulled the resident closer using a draw sheet and then turned her, resulting in the resident rolling off the bed, which was elevated about three feet from the floor. The resident sustained a 15-centimeter scalp laceration requiring wound closure with sutures and staples. Both incidents involved a failure to follow the resident's assessed needs and care plan instructions regarding the required level of staff assistance for bed mobility and repositioning. Staff involved either did not use the correct technique or did not verify and adhere to the care plan, leading to preventable accidents and injuries during routine care activities.