Failure to Provide Required Two-Person Assistance for Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for bed mobility fell from their bed while being turned by a single Certified Nursing Assistant (CNA). The resident had a history of Alzheimer's dementia, bipolar disorder, and diabetes mellitus, and was assessed as severely cognitively impaired and totally dependent on two staff for bed mobility according to their care plan and Minimum Data Set. Despite these documented needs, the CNA performed bed mobility alone, contrary to the resident's plan of care and facility policy, which required two-person assistance for such activities. On the morning of the incident, the CNA was providing incontinence care and attempted to turn the resident without assistance. During this process, the resident slid off the bed, which was positioned above the CNA's waist level, and fell to the floor. The resident sustained multiple injuries, including cuts and bleeding to the chin and forehead, a subdural hematoma, parenchymal hemorrhage, and a scalp hematoma. The resident was subsequently transferred to the hospital for further evaluation and treatment. Interviews with staff confirmed that the CNA did not request help from the other CNA on duty, despite having done so in the past for this resident. The facility's investigation determined that the CNA failed to follow the established plan of care, which clearly indicated the need for two-person assistance for bed mobility. The incident resulted in actual harm to the resident, as documented by the injuries sustained and the need for hospital transfer.