Failure to Follow Two-Person Assist Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide safe bed mobility and adequate supervision by not following a resident’s care plan requiring a two-person assist. The resident had been admitted with multiple serious injuries, including wedge compression fractures of the thoracic vertebrae, multiple left rib fractures, a left clavicle fracture, depression, and obesity, and was receiving rehabilitation services. The resident’s care plan identified an ADL self-care performance deficit related to multiple conditions and specified that bed mobility required a two-person assist. On the evening in question, a CNA entered the resident’s room alone to perform a bed check and reposition the resident, despite the care plan requirement for two staff. The resident reported that the CNA threw his legs over the bed “like a sack of potatoes,” wrenched his shoulder, shoved his left shoulder against the assist/mobility bar, and then flopped him back onto his back after stating he was dry and clean. The resident’s account of being “manhandled” and having his shoulder hit the mobility bar was documented in an incident report completed by the unit manager LPN, which noted that the CNA was the only person present during the repositioning and bed check. The resident later expressed to Social Services that the CNA was not gentle enough and stated he would consider calling the police and obtaining a personal protection order if necessary. A Doctoral Physical Therapist reported that the resident complained of being “roughed up” during care by the CNA and that he was experiencing more neck pain after the incident. The unit manager LPN and the Nursing Home Administrator both confirmed that there had been an incident during care and that there should have been two CNAs performing the bed mobility, acknowledging that the resident was not transferred properly in bed and that the care plan requirement for a two-person assist was not followed.
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