Failure to Prevent Injury During Bed Mobility Due to Lack of Clear Policies and Communication
Penalty
Summary
The facility failed to prevent injury to a resident during the provision of care, specifically while assisting with bed mobility. The resident in question had significant cognitive impairment, as indicated by a BIMS score of 03, and required substantial to maximum assistance for bed mobility, as documented in the Minimum Data Set (MDS) and daily care records. Physician orders specified the use of bilateral assist rails for bed mobility and a mechanical lift with two staff for transfers. The care plan also directed staff to use caution during transfers and repositioning to prevent injury. However, the facility was unable to provide policies regarding Activities of Daily Living (ADLs), resident transfers, or bed mobility, and the Kardex did not indicate the resident's bed mobility status. On the date of the incident, a nurse aide was assisting the resident with rolling in bed using standard technique when the resident began to push against the handrail, causing a shift in body weight and resistance. The aide applied additional pressure to complete the turn, at which point an audible snap was heard from the resident's leg area, and the resident began to scream in pain. Subsequent x-rays confirmed an acute spiral oblique subtrochanteric fracture of the proximal left femur. Documentation showed that the resident routinely required assistance of two staff for bed mobility on most days in the months leading up to the incident. Interviews with staff revealed inconsistencies in how bed mobility assistance needs were determined and communicated. Some staff relied on point of care charting, while others would ask nurses or therapy staff. The occupational therapist stated that substantial/maximal assistance did not always mean two staff were needed, and that staff were left to decide the level of assistance required. The facility's failure to provide clear policies and consistent documentation regarding bed mobility and assistance needs contributed to the incident in which the resident sustained a significant injury during care.