Failure to Ensure Safe Positioning and Adequate Staff Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant physical and cognitive impairments, including hemiplegia, vascular dementia, and functional quadriplegia, was not safely positioned in bed and did not receive the required two-person assistance for bed mobility as outlined in the care plan. The resident was dependent on staff for all mobility and personal care needs. During a morning shift, a nurse aide adjusted the height of the resident's bed without first ensuring the resident was in a safe position. The resident was on their side, near the edge of the bed, and the aide did not realize this before raising the bed. As the bed was being adjusted, the resident slid off the bed and landed on the floor in a sitting position. The incident was witnessed, and the resident was unable to verbally express pain due to aphasia. The resident was subsequently sent to the hospital, where imaging revealed an acute comminuted and mildly displaced fracture of the proximal right femur. Staff interviews confirmed that the aide did not check the resident's position or have a second staff member present, as required by the care plan, prior to adjusting the bed.