Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide provided incontinence care to a resident with a history of cerebral vascular accident (CVA), hemiplegia, and dementia, who was severely cognitively impaired and required extensive two-person assistance with bed mobility and activities of daily living. The resident's care plan and Kardex both indicated the need for two-person assistance for bed mobility. Despite this, the nurse aide proceeded to provide care alone, positioning the resident on her side and attempting to change the sheets while using only one hand to stabilize the resident. During the care, the resident began to move and subsequently rolled off the bed onto the floor, sustaining a laceration to the forehead and a nondisplaced fracture of the first cervical vertebrae (C1). The nurse aide immediately called for help, and nursing staff responded to provide emergency care and notify emergency medical services. The resident was transported to the hospital for evaluation and treatment, where the injuries were confirmed. Interviews and documentation revealed that the nurse aide did not check the Kardex prior to providing care, although she was aware from previous experience that the resident required two-person assistance. The assigned nurse and other staff were available and would have assisted if asked, but the nurse aide did not request help and attempted to perform the care alone, directly leading to the resident's fall and injury.