Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was identified as being at risk for falls and required the assistance of two persons for bed mobility, was left unattended and assisted by only one nurse aide during a routine care activity. The resident's care plan and assessment tools clearly indicated the need for two-person assistance and the use of a mechanical lift for all transfers due to the resident being non-ambulatory and on bedrest. Despite these documented requirements, the nurse aide proceeded to provide care alone and left the resident on their side while reaching for linens, resulting in the resident rolling off the bed and falling to the floor. The incident led to the resident sustaining significant injuries, including a right hip fracture, a head contusion, and multiple skin tears. The resident was sent to the emergency department, where further evaluation confirmed a right lateral impacted sub capital fracture of the hip, a temporal laceration, and additional abrasions. The resident experienced new pain following the fall, and the injuries required medical intervention, including sutures and hospital assessment. Interviews with staff revealed that the nurse aide involved was unaware of the resident's requirement for two-person assistance, despite this information being available in the resident's Kardex and care plan. Other staff members confirmed that the standard protocol is to always use two people for residents requiring such assistance and to never leave them unattended on their side. The facility's policies on fall prevention, incident management, and routine care all emphasized the importance of providing care according to individualized resident needs and minimizing accident hazards, but these protocols were not followed in this instance.