Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple sclerosis, paraplegia, a history of falls, and other significant medical conditions was admitted and later readmitted to the facility. The resident was using an air mattress and had bilateral side rails to assist with bed mobility. The care plan specified a two-person assist for transfers but did not include a two-person assist for bed mobility, despite the resident's high risk for falls and use of an air mattress. On the day of the incident, a CNA was providing a brief change for the resident. During the process, the resident rolled to her left side, let go of the positioning bar to grab her catheter, and subsequently lost control, sliding off the bed. The CNA attempted to hold the resident but was unable to prevent the fall, as the resident lost control from her hips down. The resident sustained scratches on her face and was later found to have bilateral femur fractures, requiring hospital admission. Interviews with staff revealed inconsistent understanding of the requirements for two-person assistance for residents on air mattresses. Some CNAs believed that the need for assistance depended on the resident's individual ability, while others relied on shift reports or personal observation. The DON confirmed that the resident should have had a two-person assist for bed mobility due to the air mattress, but this was not reflected in the care plan at the time of the incident.