Failure to Provide Adequate Supervision and Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who required assistance with personal care and had a history of morbid obesity and lack of coordination, was not provided adequate supervision and assistance during perineal care in bed. The resident's care plan identified a risk for falls but did not specify the number of staff required for assistance. The Minimum Data Set (MDS) assessment indicated that the resident needed physical assistance from two or more persons for bed mobility, but the Kardex listed only one-person assist. This discrepancy led to a certified nursing assistant (CNA) providing perineal care alone, during which the resident rolled off the bed and fell to the floor. Following the fall, the resident complained of pain in the right arm and was assessed by staff. X-rays were ordered, and the resident's family and physician were notified. Initial mobile x-ray results suggested acute rib fractures, but subsequent hospital imaging did not confirm these findings. The resident reported significant pain after the incident, particularly in the chest and knees. Interviews with staff revealed that the CNA had relied on the Kardex, which indicated one-person assist, despite other documentation requiring two-person assistance. Staff acknowledged the importance of verifying the correct level of assistance in the electronic health record before providing care. Further investigation found inconsistencies between the Kardex, care plan, and MDS assessments regarding the required level of assistance for the resident. The facility's policy required accurate communication and documentation of assistance needs, but this was not followed in this case. The failure to ensure that all care documentation matched and to provide the correct number of staff for bed mobility directly led to the resident's fall and subsequent pain.