Failure to Protect Resident from Neglect During Bed Mobility Assistance
Penalty
Summary
The facility failed to protect a resident from neglect during the provision of incontinence care. According to the clinical record and staff statements, a resident with diagnoses of muscle weakness, debility, and dementia, who required assistance with bed mobility, was being assisted by a nurse aide. The aide rolled the resident away from herself while changing the sheets, contrary to published safe bed mobility guidelines and the resident's care plan, which resulted in the resident rolling out of bed and experiencing an assisted fall. The aide attempted to prevent injury by grabbing the resident's gown, allowing the resident to slide gently to a sitting position on the floor. Facility documentation and staff interviews confirmed that the resident was an assist x1 for bed mobility and that the aide did not follow proper procedures for repositioning. The incident was substantiated as neglect, as the facility's policy defines neglect as the failure to provide necessary goods and services to a resident. The deficiency was identified through review of facility policy, clinical records, and staff interviews, which established that the resident was not protected from neglect during the incident.