Failure to Provide Required Two-Person Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, functional quadriplegia, and functional limitations in both upper extremities, was not provided with the required level of assistance during bed mobility. The resident's care plan and nursing Kardex specified that two staff members were needed to assist with bed mobility and repositioning. Despite these documented requirements, a nurse aide attempted to roll the resident alone while changing bed sheets, resulting in the resident rolling off the bed. Facility documentation and staff interviews confirmed that the nurse aide did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The Director of Nursing stated that residents should always be rolled toward the caregiver, and the Nursing Home Administrator confirmed that the care plan was not followed. This failure to provide adequate supervision and assistance directly led to the accident involving the resident.