Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on two staff members for bed mobility and positioning, was provided care by only one CNA. The resident's care plan and CNA Care Card both indicated the need for assistance from two staff members for bed mobility and positioning due to significant physical and cognitive impairments, including unspecified dementia with agitation and adjustment disorder. Despite these documented requirements, the CNA did not consult the Care Card prior to providing care and was unaware of the resident's need for two-person assistance. During morning care, the CNA attempted to reposition the resident alone. While the CNA was preparing to provide incontinent care, the resident began to slide off the bed. The CNA tried to reposition the resident but was unable to prevent the resident from sliding off the bed and falling to the floor. Another CNA was present in the room but was attending to a different resident and did not assist with the care of the resident in question. The incident was witnessed, and the resident was assessed to have no injuries immediately following the fall. Interviews with staff confirmed that the CNA responsible for the resident's care did not check the Care Card and was not familiar with the resident's specific care needs. The facility's policy required all caregivers to be aware of and follow care plan interventions, and the Care Cards were accessible at the nursing station. The failure to consult the Care Card and provide the required level of assistance directly led to the resident's fall from bed during care.