Failure to Provide Required Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide the required two-person assistance for bed mobility to a resident with an air mattress, as specified in the resident's care plan and assignment sheet. The resident, who was cognitively intact and had diagnoses including depression, hypertension, and diabetes, required total assistance for toileting and bed mobility, and substantial assistance for bathing. The care plan clearly indicated that two staff members were needed for bed mobility tasks due to the increased risk of injury associated with the air mattress. On the day of the incident, the NA placed the resident in a lateral position near the edge of the bed and left the resident unattended while stepping out to consult with a nurse about a spinal cord stimulator. During this time, the resident rolled out of bed and sustained injuries, including a hematoma on the left side of the forehead, a laceration above the left eye, and a hematoma to the right knee with associated pain. The NA later stated that she was unaware of the two-person assistance requirement, despite the assignment sheet reflecting this instruction. Multiple staff interviews confirmed that the assignment sheets contained information about required assistance levels and that residents on air mattresses or with similar needs should not be left unattended during care. The incident resulted in actual harm to the resident, as documented by physical assessments and progress notes, and was acknowledged by the Director of Nursing as a failure to provide appropriate goods and services to prevent falls, constituting neglect.