Failure to Provide Two-Person Assist for Bed Mobility as Directed by Care Plan
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided activities of daily living (ADL) care to a resident who was dependent on staff for bed mobility, as documented in the resident's care plan and Kardex. The care plan specified that the resident required the assistance of two staff members for all bed mobility tasks, including rolling side to side. However, during an observation, the CNA performed catheter and peri care with only a one-person assist, instructing the resident to roll independently and rolling the resident away from herself rather than towards herself. The resident was observed to be very close to the edge of the bed during this process, and there were no handrails present to prevent a fall. Further review of the resident's records confirmed the requirement for two-person assistance with bed mobility. In interviews, the CNA stated she believed the resident was a one-person assist and had last reviewed the care plan three days prior. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and that staff should roll residents towards themselves, not away. The failure to follow the established care plan and facility protocols for bed mobility assistance led to the deficiency.