Failure to Provide Adequate Supervision and Accident Prevention During Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. The resident, who had diagnoses including hypertension, heart failure, and dementia, required extensive assistance from two staff members for bed mobility, as documented in the Minimum Data Set. However, the care plan and physician orders did not clearly specify the required assistance for bed mobility, and fall mats, which were ordered to be placed bilaterally at the bedside, were not in place at the time of the incident. During care, a nurse aide was changing the resident and turned away to grab a brief, at which point the resident rolled out of bed and fell, sustaining a left hip fracture. The bed was elevated to over two and a half feet, and the fall mats were not present as required by the care plan and physician order. Witness statements from staff confirmed that the fall mats were not in place and that the nurse aide left the resident's side during care, contrary to facility policy and the resident's needs. The Director of Nursing also confirmed that the nurse aide's account of the incident was inconsistent with the physical evidence and that the aide failed to provide adequate supervision. The facility's policies on accident investigation and activities of daily living were not followed, contributing to the resident's fall and injury.