Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who required assistance with bed mobility due to muscle weakness, debility, and dementia. According to the clinical record and staff statements, the resident was being assisted by a nurse aide with incontinent care and sheet changing when the aide rolled the resident away from herself, contrary to published safe bed mobility guidelines. As a result, the resident rolled out of bed and experienced an assisted fall, coming to rest in a sitting position on the floor. The resident's care plan indicated the need for assistance with changing position in bed, and the aide's actions did not align with the recommended procedure for such assistance. Facility documentation and staff interviews confirmed that the aide involved rolled the resident in a manner inconsistent with both the resident's care plan and established safety protocols. The incident was substantiated as neglect, as the transfer status and required supervision were not properly followed during the provision of care. The deficiency was identified through review of facility documents, clinical records, and staff interviews, which collectively demonstrated a lapse in supervision and adherence to safe care practices for residents requiring assistance with bed mobility.