Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, hypertension, and dysphagia, who required maximum assistance with all activities of daily living and specifically two-person assistance for bed mobility and incontinence care, was not provided the required level of assistance. The resident's care plan and Kardex clearly indicated the need for two-person physical assistance for bed mobility and brief changes. Despite this, a CNA entered the resident's room alone to change the bed while the resident was still in it, did not notice the posted sign indicating the required assistance level, and attempted the task without a second staff member present. During the process, the resident rolled off the bed and fell to the floor, hitting their head and complaining of elbow pain. The incident was witnessed by staff who responded to the CNA's call for help. The resident was assessed by a nurse and subsequently sent to the hospital for further evaluation due to being on blood thinners. Interviews with staff confirmed that the resident's need for two-person assistance was documented and known, but the protocol was not followed at the time of the incident.