Failure to Provide Required Assistance During Bed Mobility Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, Parkinsonism, and muscle weakness, who was non-verbal and totally dependent on two staff for bed mobility, was not provided the required level of assistance during repositioning in bed. The resident's care plan and task orders clearly indicated that two staff were needed for rolling side to side, and this requirement was documented in multiple reviews and confirmed by staff interviews. Despite these documented requirements, an agency CNA attempted to roll the resident independently without assistance. During this process, the resident rolled out of bed and struck their head on the roommate's bed frame, resulting in a 3 cm laceration to the right forehead and subsequent bruising. The incident was witnessed by another CNA who responded to noises from the room and found the resident partially out of bed and the agency CNA attempting to assist them back onto the bed. Following the incident, the resident was assessed and found to have a significant laceration and was in considerable pain. A CT scan at the hospital revealed a small acute bilateral intraventricular hemorrhage. The agency CNA involved stated they were unaware of the resident's stiffness and did not know that two staff were required for the task. The failure to follow the care plan and task orders for bed mobility assistance directly resulted in actual harm to the resident.